House of Lords

Wednesday 28th October 2026 Lords Chamber

Wednesday 28 October 2026

15:00

Prayers—read by the Lord Bishop of Gloucester.

Adults Lacking Mental Capacity: Child Trust Funds

Wednesday 28th October 2026 Lords Chamber

Question

15:06

Asked by

[Lord Young of Cookham]

To ask His Majesty’s Government what progress has been made in enabling access to Child Trust Funds on behalf of adults who lack mental capacity.

[The Parliamentary Under-Secretary of State, Ministry of Justice (Lord Lemos) (Lab)]

My Lords, the Government are considering all potential options to resolve the issue of access to child trust funds. The round table held in July, hosted by my noble friend Lady Levitt, provided valuable perspectives on all options, and officials are moving forward with this work. The Government cannot endorse the banks’ exceptional processes. It is not consistent with the framework established by the Mental Capacity Act 2005 and the common-law principles that underpin it. However, we recognise the need to find a solution to this problem so that the money can reach those who own and need it.

[Lord Young of Cookham (Con)]

My Lords, I am grateful for that reply. Some £250 million is locked up in child trust funds, built up by children who are now adults but have a learning disability. The Government insist that the only way that these sums can be unlocked is by going through the Court of Protection, a cumbersome and at times expensive process that can take between six and 12 months. This deters many applicants and so the benefits are forgone. Will the Minister transform the lives of some 80,000 young people by building on the excellent work of his predecessor, the noble Baroness, Lady Levitt, who recognised that the present system was not fit for purpose, and promote quick and easy access to these funds to bring to an end a manifest injustice?

[Lord Lemos (Lab)]

I thank the noble Lord. We understand the seriousness of this problem and remain committed to resolving this long-standing issue of access to child trust funds for young adults who lack mental capacity. This is a high priority for Minister Richards, who has engaged extensively with stakeholders and wants to move quickly towards a practical solution. The Government are very hopeful of making progress in the coming weeks.

[Baroness Levitt (Lab)]

My Lords, the law currently requires parents of disabled adult children to navigate procedures which were designed to protect vulnerable people from fraud and financial abuse. Does my noble friend the Minister agree that, where parents are simply seeking to access a child trust fund or junior ISA on behalf of a son or daughter for whom they have cared all their lives, there is a strong case for a bespoke and proportionate process which starts from a position of trust rather than one of suspicion?

[Lord Lemos (Lab)]

I agree with my noble friend. Of course we do not think that all parents are a danger to their children; that would be ridiculous. As I have said, Minister Richards is looking for a solution in the coming weeks. However, as I am sure my noble friend would agree, not every adult has loving parents and the principles that underlie the Mental Capacity Act about adults—we are talking about adults—being entitled to agency over their own funds is an important one.

[Baroness Pinnock (LD)]

My Lords, at least three-quarters of a million funds have been unclaimed so far, and they are attracting “kindly tracer agents”—though scammers might be a more apposite description. What do the Government intend to do to enable those 750,000 young people to get access to those funds?

[Lord Lemos (Lab)]

The noble Baroness makes two points. I very much agree with the first one. It is deeply shocking, not just with this group of people but others, that scammers target people who lack mental capacity or have intellectual or learning disabilities. It is deeply immoral and disgraceful. On the question of accessing these funds, as I said to the noble Lord, Lord Young, we are working actively towards a solution to this problem and Minister Richards hopes to announce something in the coming weeks.

[Baroness Finlay of Llandaff (CB)]

My Lords, following on from the very helpful meeting that the noble Baroness, Lady Levitt, held with several of us who have been concerned about this for many years, could the Minister tell us when there have been meetings with the Court of Protection to develop a fast-track process that would be compatible with the Mental Capacity Act and avoid the delays and expenses that are incurred, but recognise that these funds mature when the child becomes an adult at the age of 18 and that they are therefore legally an adult-to-adult transfer?

[Lord Lemos (Lab)]

The noble Baroness knows that, since 2020, various changes have been made to the Court of Protection framework to make this easier and cheaper to deal with. I will not answer her question specifically, because this work is actively under way, but I am very happy to set out exactly what the arrangements are for the Court of Protection. It is important to reiterate that the Mental Capacity Act is there to protect people’s rights. We do not want to undermine that in any way, and we will not, but we will seek a solution to this problem.

[Baroness Kramer (LD)]

My Lords, this House used the opportunity of the Financial Services and Markets Bill to send an amendment to the other place which would enable the FCA to, in effect, enable financial institutions to release these funds based on their existing knowledge of the relationship between the parents, guardians and young people, whom they know because for many years those parents and guardians have been managing large sums of public money on that child’s behalf. Will the Government please take that seriously as the Bill is addressed down the other end, because it gets us around the dynamic of having to make very extensive changes to the Mental Capacity Act and delivers a practical solution?

[Lord Lemos (Lab)]

I am well aware of the amendments that the noble Baroness put down on child trust funds and junior ISAs. It is fair to say that slightly different issues are involved in child trust funds and junior ISAs, but, as I say—and I hope she can take some reassurance from this—we have considered her amendments, which are now in the other place, and thinking about a solution which resolves the issue of principle here, which is that parents who care for their children in a loving and trusting way should be able to help those now young adults to get access to these funds.

[Lord Keen of Elie (Con)]

My Lords, the Prime Minister has consistently talked of making quick fixes—although apparently that does not include the economy or defence. We have heard from noble Lords, including the noble Baroness, Lady Kramer, that this trust fund issue could be easily and quickly fixed. Will the Minister undertake to share the proposal with our quick-fix Prime Minister?

[Lord Lemos (Lab)]

I should demur from those observations about the economy and defence, having listened to the Budget with enthusiasm. I am not sure about quick fixes, but I am sure that the Prime Minister is aware of the need to resolve this problem. We will do so, because it has gone on too long; I do not seek to pretend otherwise.

[Lord Macintosh of Eastwood (Lab)]

My Lords, I thank my noble friend the Minister for the work he is doing to improve access to child trust funds for young people with reduced capacity. However, is he aware that there are thousands of disadvantaged young people who are not even aware that they have these child trust funds? Is he aware of the work of the Share Foundation, in particular the campaign for release at 21, and will he look into that with a view to liberating these funds for people who need them?

[Lord Lemos (Lab)]

I am aware of that work, and I pay tribute to all the charities and other campaigners. I pay particular tribute to Andrew Turner, who has been heavily involved in this campaign on behalf of his son, Mikey, and to Sir Ed Davey, the leader of the Liberal Democrats, whose thoughtful and persistent advocacy has done so much to ensure that this issue receives the attention it deserves.

[Noble Lords]

Hear, hear!

[Lord Lemos (Lab)]

I should have paused there. I endorse that “Hear, hear”—on this issue. The noble Lords, Lord Young and Lord Blunkett, have also played an important advocacy role on this subject. This is an important campaign and those are interesting and important proposals, and I thank the noble Lord for raising my good work—but, in fact, it is the work of Minister Richards and, before him, my noble friend Lady Levitt.

[Baroness Morris of Bolton (Con)]

My Lords, the Minister said he would write to the noble Baroness, Lady Finlay of Llandaff, to say what was happening with the Court of Protection. Could he also undertake to place a letter in the Library, because I am sure we would all like to know what the Court of Protection is doing on this?

[Lord Lemos (Lab)]

Yes, of course I will.

[Baroness Lister of Burtersett (Lab)]

My Lords, could my noble friend explain why the proposal for automatic release at 21 has not been accepted?

[Lord Lemos (Lab)]

I am not sure I quite said that. My noble friend will need to wait for the government announcement, which will come not in due course but in the coming weeks.

Vocational GCSEs

Wednesday 28th October 2026 Lords Chamber

Question

15:17

Asked by

[Baroness Barran]

To ask His Majesty’s Government what empirical evidence underpins the Secretary of State for Education’s assertion that the introduction of vocational GCSEs will not lead to disadvantaged pupils being disproportionately steered towards vocational or non-academic pathways; and what measures they will take to safeguard against any perception of lowered expectations.

[The Minister of State, Department for Education and Department for Work and Pensions (Baroness Smith of Malvern) (Lab)]

My Lords, this approach to developing technical routes and vocational GCSEs is not about separating pupils into academic or vocational routes at age 14; rather, it is about widening pupils’ choices and supporting coherent progression into a range of academic and technical post-16 options. The new technical education routes will provide every young person with a clear path into further study, apprenticeships or skilled work by combining academic excellence in core subjects with rigorous vocationally focused qualifications of equal parity and esteem as traditional GCSEs.

[Baroness Barran (Con)]

My Lords, I am not sure I heard in the Minister’s Answer any of the robust evidence that I asked for, but I accept the Government’s intentions. The Government have justified their pivot towards generic skills and vocational routes by suggesting that a knowledge-based academic curriculum has contributed to the high level of NEETs among our young people. Given that education is devolved and that Wales and Scotland have pursued these vocational routes for many years and their levels of NEETs are higher than ours, will the Minister concede that stripping academic rigour from our classrooms is a false remedy to a structural economic problem?

[Baroness Smith of Malvern (Lab)]

Evidence actually suggests that the existing technical awards are taken slightly more often by disadvantaged pupils. That is one of the reasons why we are reforming the system so that pupils’ choices are driven by their interests and aspirations, rather than their background. The noble Baroness suggested that this Government have said that knowledge is not important in the curriculum. That is wholly wrong. As the noble Baroness will see when we publish our curriculum plans, following the Curriculum and Assessment Review, we have been clear throughout that knowledge is a key element of the curriculum. But it is possible to deliver high-quality academic standards and deep knowledge alongside the opportunity for pupils also to develop vocational and technical skills in a way that provides a broad and deep curriculum that is currently missing.

[Lord Addington (LD)]

My Lords, will the Minister give us some indication of what advice the Government are giving not only to pupils but to the parents of these pupils about the value of these new qualifications? If we are to get people taking subjects they have an aptitude for, as opposed to what is seen to be the desirable thing by somebody else, we will need to make sure that people understand that process.

[Baroness Smith of Malvern (Lab)]

The noble Lord makes an important point. We will consult on the content and nature of vocational GCSEs very soon, this autumn. Because this is about technical pathways delivered and developed at a local and regional level, we are also working closely with mayoral authorities, employers and others. I am sure that they, as we do, will want to ensure that there is strong advice for parents and clear information about what it means to take a vocational GCSE as part of that broad curriculum.

[Lord Roe of West Wickham (Lab)]

My Lords, I declare my interest as the chair of the Building Safety Regulator. I think it is fair to say that it is well understood across both sides of this House that the construction economy is one of the most important parts of our wider economy. It employs 2 million people, but it will run about 40,000 construction workers short every year between now and 2030. I know that the new proposed vocational GCSE for building construction has been widely welcomed by the industry, but what specific work is being done to ensure that the curriculum and syllabus are built on the needs of the industry and in conjunction with the industry?

[Baroness Smith of Malvern (Lab)]

My noble friend makes an important point. These qualifications must align with and be informed by what the industry sees as important, because that is what provides the opportunity for the young person to know that they are on a pathway that can lead to good work. That will be a key element of the consultation starting soon.

[Lord Hampton (CB)]

My Lords, as with the UTC Question last week, the Government are in danger of asking questions that they should know the answer to. Does the Minister agree that there already is an intellectually rigorous vocational subject? It is called design and technology, and I teach it. All they need to do is reopen the workshops, recruit specialist teachers and get parity of esteem with parents and metrics.

[Baroness Smith of Malvern (Lab)]

I am sure the noble Lord does a very good job of delivering design and technology classes. He will have noted that, in response to the Curriculum and Assessment Review, the Government have been clear that we want to create both more space and more value to some of the courses that have been lost over previous years. In delivering this broad curriculum, we want to be clear—this will be part of the consultation—about what is necessary in terms of equipment, the estate of the school and the training of teachers.

[Baroness Cash (Con)]

My Lords, I fear the Minister misheard the noble Baroness, Lady Barran, who criticised the Government not on the academic curriculum but for saying said that it had contributed to the number of NEETs. The Government are on record as saying that. It is of real concern to many educationalists, who have already seen a focus on skills in Scotland and Wales accelerate the number of NEETs there. How will the Government assess and monitor whether disadvantaged pupils with good results at age 11 are more likely to be entered for a vocational GCSE than a better-off pupil with the same results, which is steering and lowering expectations? We are very keen to understand how the Government will ensure that does not happen.

[Baroness Smith of Malvern (Lab)]

I am very happy to go back and look at the record, but I think the noble Baroness, Lady Barran, said that the Government had said that a knowledge-based curriculum—well, let us look at the record.

My point remains that we are providing for a strong and deep academic curriculum alongside options for students to study more technical and vocational courses. The noble Baroness makes an important point, and with the evidence, some of which I have already cited, and the work we do in developing vocational GCSEs, we want to be very clear that this is providing higher standards and better opportunities for all students. We will make sure that that is part of the development, monitoring and evaluation.

[Lord Mohammed of Tinsley (LD)]

My Lords, I will just follow up on the issue of monitoring and evaluation, in particular on the collection of data. Previously, we have heard the Conservative Front Bench talk about disadvantaged young people, but I want to add young people from minority backgrounds and young people with special educational needs. Will the Government collect data on those young people to see what level of take-up they have by region and to ensure that young people from those backgrounds are not being disproportionately funnelled toward vocational GCSEs rather than the more academic route? Will the Government commit to publishing that data?

[Baroness Smith of Malvern (Lab)]

To be clear, every student will continue to do English, maths and science. That is a really important element of the academic opportunities that are open to them. It is important that these vocational GCSEs sit within technical pathways that are developed at a regional level and therefore are much more likely to be able to recognise the needs and opportunities for young people within those areas. That too will be part of the evaluation.

[Baroness Blower (Lab)]

My Lords, does my noble friend agree that many students were disadvantaged by the previous straitjacket of a curriculum that did not allow for anything like enough access to creative subjects and allowed perilously small access to technical subjects? Does she also agree, therefore, that widening the possibility for all young people is an extremely good idea?

[Baroness Smith of Malvern (Lab)]

Yes, I do agree with my noble friend. That was also the conclusion of the independent Curriculum and Assessment Review, on which the Government will bring forward proposals in the near future. I reiterate that the requirement to continue with English, maths and science, to put vocational GCSEs alongside rigorous academic subjects where that makes sense for the students, is an important part of our proposals. Another is ensuring that these new qualifications meet the highest possible standards, being based on nationally set criteria—which current technical awards are not—and being available for all students. They should be something not that students are funnelled into but that open doors and opportunities for them.

LED Lighting: Health Effects

Wednesday 28th October 2026 Lords Chamber

Question

15:27

Asked by

[Lord Davidson of Glen Clova]

To ask His Majesty’s Government what assessment they have made of the developing science on the adverse health effects of LED lighting.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, the risk to the general population is considered low. Potential health risks from lighting are not unique to LED lighting. The Government continue to monitor evidence on the health impacts of LED lighting, publishing guidance on flicker reduction and healthy lighting environments. The UK Health Security Agency contributes to international research and standards and works with experts to better understand how light exposure affects health and to promote good lighting design.

[Lord Davidson of Glen Clova (Lab)]

I thank my noble friend the Minister for her response. I congratulate the NHS on the new Moorfields hospital, which will open next year. However, given the cutting-edge research that has been carried out at UCL on the link between daylight and health effects, can my noble friend assure the House that the new hospital will avoid the problems of 100% LED lighting?

[Baroness Merron (Lab)]

I too very much welcome the new Moorfields hospital which, as my noble and learned friend says, is to open next year. The architecture integrates national daylight with 100% LED lighting. I can assure the House that it has been developed in accordance with applicable net-zero design standards, approvement requirements, technical standards and assurance processes, as I am sure noble Lords would expect. We are seeking confirmation from the trust about any daylighting studies or assessments that have been undertaken as part of the design process. When I get that information, I will be very pleased to write to my noble and learned friend.

[Lord Robathan (Con)]

My Lords, what research is being done on the effects of high-visibility headlights on cars? I am not sure whether they are LED, but they are causing people to have accidents.

[Baroness Merron (Lab)]

The DfT is undertaking independent research and is approaching this with regulatory changes and through international safety standards. The noble Lord raised the question of why glare is a problem. The Which? report on this, published only yesterday, talked not just about brighter LED but the height of vehicles and beam alignment. The DfT has just this week updated driver advice in the Highway Code on this very point, encouraging people to get it checked.

[Baroness Pidgeon (LD)]

My Lords, the Advertising Standards Authority upheld a complaint in June about an LED face mask that claimed it was clinically proven it could reduce wrinkles in four weeks.

[A noble Lord]

Who bought it?

[Baroness Pidgeon (LD)]

Exactly. Given there are numerous adverts for at-home LED beauty devices in the run-up to Christmas, will the Government urgently assess whether existing regulation adequately protects consumers in terms of product safety and the evidence supporting claims about health benefits?

[Baroness Merron (Lab)]

This is ongoing work. If it was a true claim, I am sure that many noble Lords would have been very keen to benefit—me included.

[Noble Lords]

No!

[Baroness Merron (Lab)]

How kind. But quite seriously, it is good that the Advertising Standards Authority is looking into this. We have regulations to ensure that people are not misled and are protected. Tangentially but linked, I am sure that the House would welcome our recent work on cosmetic surgery regulations, which really strengthens this point.

[Baroness Rafferty (Lab)]

My Lords, does the Minister agree that the practice recently put in place by King’s College Hospital of exposing intensive care patients to daylight has promoted their earlier recovery and should be adopted by other NHS trusts?

[Baroness Merron (Lab)]

My noble friend is absolutely right to highlight the fantastic King’s critical care roof garden. I was very pleased to see the media coverage of it earlier this year. Not only are the team providing full life support to the patients, staff and families, allowing them to feel the therapeutic effects of being outside and in nature, but they are using the spaces they have developed for research on whether it gives the right support and enhances people’s health. I am very much looking forward to what they come up with. It is very impressive on top of their medical excellence.

[Lord Evans of Rainow (Con)]

My Lords, given the growing evidence that exposure to artificial light at night can disrupt sleep and the circadian rhythms, does the Minister agree that the Government should do more to ensure that the public are aware of these potential health risks? Will the Minister commit to updating existing public health guidance to reflect the latest scientific evidence?

[Baroness Merron (Lab)]

If there are particular things the noble Lord thinks the Government are not doing, I would be very pleased to receive details. I am glad that he did not refer specifically to LED lighting. As I have said, there is no evidence that it is directly harmful in normal use in the general population. However, through the Committee on Medical Aspects of Radiation in the Environment, we are developing an evidence-based review programme on artificial light and health, just as he asks, and gathering evidence and identifying gaps. We are also supporting research and working internationally. I would be very pleased to give further details if the noble Lord would like.

[Baroness Hayter of Kentish Town (Lab)]

I will revert to the question of headlights that people know I have been campaigning on. With LED lights, there are questions both about the luminance—that is, the strength —and about it being a blue light rather than the softer yellow of halogen lights. Would my noble friend agree to put the expertise at the Department of Health together with that at the Department for Transport, which is doing good research on this, so we can make sure these two lots of expertise tie up together?

[Baroness Merron (Lab)]

The policy for lighting is shared across a number of departments—not just the Department for Health and Social Care but the Department for Transport, as my noble friend says, as well as the Department for Energy Security and Net Zero, the Department for Business, Innovation, Science and Trade, and a number of arm’s-length bodies. We do all indeed co-ordinate and, as I mentioned earlier, work internationally, particularly with the UN Economic Commission for Europe, because we need to ensure that we update international vehicle lighting to meet the point that my noble friend is concerned about.

[Lord Patel (CB)]

My Lords, the Minister referred to blue light and its effect on children, which is correct, but a similar biological effect occurs in the retina of children based on the amount of time they spend on screen usage, particularly at night, because, as mentioned already, it disrupts melatonin production, which disrupts sleep. The same effect happens based on the length of time children use screens as for LED lighting, particularly higher-wavelength LED lighting. I thank the Minister for commenting on that.

[Baroness Merron (Lab)]

The noble Lord is quite right and highlights exactly the point I was making earlier on the first question about cars and lighting. There are a number of factors. Screen use can indeed be harmful, particularly where it replaces sleep, physical activity or leisure time. As the noble Lord will know, we advise families with under-fives to limit screens around bedtime and to ensure that content is age appropriate. I know that our department and the Department for Education will be publishing wider guidance for five to 18 year-olds in January.

Independent Football Regulator

Wednesday 28th October 2026 Lords Chamber

Question

15:37

Asked by

[Lord Harlech]

To ask His Majesty’s Government what oversight they intend to exercise over the budget of the Independent Football Regulator following its proposal for a levy of £20.3 million a year, around double the amount originally estimated.

[The Parliamentary Under-Secretary of State, Department for Digital, Culture, Media and Sport (Baroness Lloyd of Effra) (Lab)]

My Lords, the Government are proud of the success of football in this country, so I start by congratulating England captain Harry Kane on winning the Ballon d’Or this week.

The Independent Football Regulator, led by its board, rightly sets its budget independently of government. The regulator is currently consulting on its proposed levy, and we encourage football to engage fully so that the levy is shaped by those paying it. The proposed levy represents 0.2% of football’s annual revenues of £9 billion last year. As a public body, the regulator is subject to standard guidance and controls and will lay its annual report before Parliament.

[Lord Harlech (Con)]

My Lords, the regulator’s proposed operating costs have doubled already, and it is not even operational yet. That is together with a set-up cost of £45 million over 10 years, which was in no part of the original estimate. These are exactly the kind of problems that these Benches raised during the passage of the Bill and we were admonished, in this House and in the press, for slowing the Bill down. What powers do the Government hold to challenge the regulator’s budget before the levy begins next season and how will Parliament be able to scrutinise those costs once central funding ends?

[Baroness Lloyd of Effra (Lab)]

As I mentioned before, the proposed levy represents 0.2% of football’s annual revenues of £9 billion last year. We believe that this is affordable by football. The budget is set by the regulator as an independent regulator. It will lay its report to Parliament to allow scrutiny of that. The State of the Game report, published only recently, underlines the need for change and for this regulator.

[Lord Grantchester (Lab)]

My Lords, along with the Prime Minister, I am proud to declare my interest in and support for Everton Football Club. To clarify how costs have risen, can my noble friend the Minister outline the action the independent regulator has taken to establish itself since its creation last year? It may be helpful to understand what engagement the regulator has had with every regulated football club about this proposed levy.

[Baroness Lloyd of Effra (Lab)]

My noble friend is right to highlight the action that has been taken since the regulator has been set up. The regulator has already published its State of the Game report, begun testing owners, directors and senior executives, protected club heritage by ensuring that fans are consulted on key decisions, and issued 10 consultations alongside final rules and guidance. The regulator’s CEO has written to all clubs ahead of the levy consultation, which will run until 4 December, and we encourage all clubs to respond and help shape the methodology that will determine the levy they pay.

[Lord Addington (LD)]

My Lords, we are looking at an industry that has 116 units being regulated, generates £9 billion and has 94% of its units operating at a loss. Can the noble Baroness think of any industry that is actually calling out more for regulation?

[Baroness Lloyd of Effra (Lab)]

The noble Lord makes a point that I heartily agree with. The State of the Game report underlines the issues with financial stability, governance and the structure, and underlines the need for the Independent Football Regulator to operate and use the powers it has in the three objectives of club financial soundness, working on the systemic financial resilience of the whole football pyramid, and safeguarding club heritage for fans.

[Lord Londesborough (CB)]

My Lords, let me put this £20 million into context. Although we have heard that the top five tiers of the football league generate some £9 billion in annual revenues, almost every club is deep in the red, losing money year after year. As we know, one club, Man City, has been found guilty of 114 financial breaches totalling £900 million over a period of eight years—eight unregulated years. That is the point. Does the Minister agree that the £20 million cost of the new regulator may well be over budget but is hardly excessive?

[Baroness Lloyd of Effra (Lab)]

I absolutely agree with the point that the noble Lord makes. The structure and methodology that the Independent Football Regulator is consulting on puts the burden, as it were, on Premier League clubs with a higher cost. National League clubs will pay much less per season because it is a revenue-based model.

[Lord Hayward (Con)]

My Lords, will the Minister please write to the House, and particularly to my noble friend Lord Harlech who asked the Question, explaining how the Government managed to produce an impact assessment that is already more than 100% inaccurate? At the same time, could she please write to the smaller clubs that are going to face the costs associated with this regulator and apologise to them for the answers that were given so often during the passage of the Bill that they would not face more than the £10 million that was identified in the impact assessment in the first place?

[Baroness Lloyd of Effra (Lab)]

I stand to be corrected by noble Lords who were here during the initial phases of the Bill, but I believe that the impact assessment was published under the previous Government. Indeed, that impact assessment was heavily caveated. It was decided during the passage of the Bill setting up this independent regulator that it should set its own budget, and that is the way that we have proceeded.

[Baroness Taylor of Bolton (Lab)]

My Lords, does the Minister agree that the Independent Football Regulator has shown great willingness to engage with Members of this House and the other place, and that that is quite unusual for many regulators? Does she also agree that his interventions so far have been constructive in saving at least one football club?

[Baroness Lloyd of Effra (Lab)]

My noble friend is right to highlight the engagement that the Independent Football Regulator has had, although I stress that the regulator remains independent and is taking operational decisions, as he makes clear.

[Lord Evans of Rainow (Con)]

My Lords, I associate myself with the Minister’s comments on Harry Kane and congratulate him. From Leyton Orient on loan to the Ballon d’Or—what a player and what a role model for our young people.

During our debates on the Bill, noble Lords on this side of the House repeatedly raised concerns that this regulator would not be light touch, as the Government claimed, and that it would be captured by scope creep. Given the levy rate and the larger budget recently announced, does the Minister agree that these Benches were right and the Government were wrong?

[Baroness Lloyd of Effra (Lab)]

I cannot agree with that. State of the Game underlines the need for reform, the parlous state of the financial sustainability, the governance failings and the systemic resilience of the game, and it underlines the need for action. The Independent Football Regulator has a tightly defined scope. It has three objectives and it needs the resources to operate as it does, but it will do so in the most efficient and expedient way.

[Lord Razzall (LD)]

My Lords, in the light of the Minister’s answer on the earlier question, will she confirm that this means that the Government and the Prime Minister will not attempt to intervene in the Manchester City story that the noble Lord, Lord Londesborough, mentioned, thereby avoiding the resignation of the regulator?

[Baroness Lloyd of Effra (Lab)]

The case involving Manchester City is an independent process concerning a breach of the Premier League’s rules. It is not for the Government to intervene, particularly as we know that an independent commission is currently considering the appeal lodged by Manchester City Football Club.

[Baroness Debbonaire (Lab)]

My Lords, as my noble friend the Minister mentioned, but it is worth repeating, the cost of the regulator is 0.2% of the value of a £9 billion industry, but the clue is in the name: it is an independent regulator. It was originally a Tory Bill but during the wash-up it failed to get through before the election. I am proud of the fact that a Labour Government have brought this in. I am sure that the noble Lord, Lord Harlech, like me, has read all 245 pages of the State of the Game report—as every noble Lord should; it is weekend reading. It provides crystal-clear evidence of why we need this regulator. It will be getting on with licensing in the coming weeks, which is a huge piece of work. I invite my noble friend the Minister to congratulate the Independent Football Regulator and the Secretary of State on bringing it in.

[Baroness Lloyd of Effra (Lab)]

I am only too happy to accede to my noble friend’s request to congratulate the Independent Football Regulator on its report and the Secretary of State for her work in bringing this in.

Enterprise Act 2002 (Specification of Additional Section 58 Consideration) Order 2026

Wednesday 28th October 2026 Lords Chamber

Motion to Approve

15:48

Moved by

[Baroness Anderson of Stoke-on-Trent]

That the Order laid before the House on 12 October be approved.

Relevant document: 13th Report from the Secondary Legislation Scrutiny Committee (special attention drawn to the instrument). Considered in Grand Committee on 27 October.

Motion agreed.

Electronic Monitoring of Offenders

Wednesday 28th October 2026 Lords Chamber

Commons Urgent Question

15:50

The following Answer to an Urgent Question was given in the House of Commons on Tuesday 27 October.

“The Government inherited a justice system pushed to breaking point by the previous Government. When Labour came to power, we had fewer than 100 places left in our prisons, with incredibly serious problems with electronic monitoring. We have taken swift action to improve performance, and are now delivering the biggest expansion of tagging in British history, backed by £100 million of investment.

As part of our reforms, there is a presumption that eligible offenders released under the progression model will be tagged, giving the Probation Service an additional tool to monitor offenders and protect the public. We are now tagging a record number of offenders, helping to cut crime and make our streets safer.

Electronic monitoring is not used in isolation. Those released from prison remain subject to licence conditions and probation supervision, which can include curfews and restrictions on their movements. We have also introduced tougher powers for probation officers, including world-first restriction zones for the most serious sexual and violent offenders where appropriate, as well as the ability to prohibit offenders from driving, attending public events or entering pubs, clubs and bars. Where an offender breaches their conditions or can no longer be safely managed in the community, they can immediately be recalled to prison.

We have also ensured that the Electronic Monitoring Service is ready to support the expansion. The service was ready for first-tranche releases on 1 October, with the equipment and staff in place to deliver the presumption to tag offenders on release. Serco has consistently met its contractual requirements since March 2026.

The Ministry of Justice routinely publishes extensive data on probation and tagging. It is published quarterly, and the last set of data was published just last week. It is vital that the Government and the public have confidence that the information published by the department is accurate. Our quarterly economic monitoring statistics, including figures for the number of prison leavers fitted with tags and the figures covering the October period, will be publicly available in January.

This Government inherited a prison system on the brink of collapse, with just 500 places being built in the last 14 years. It is this Government who are now building the prison places we need and putting in the strictest measures possible to protect the public”.

[Lord Keen of Elie (Con)]

My Lords, we are aware that more than 5,000 released offenders were not fitted with tags in the first half of this year and consequently went unmonitored on their release. With the pressure that the early release scheme has placed on the system, that number is liable to have increased. Can the Minister tell the House what proportion of prisoners released as part of the early release scheme were not tagged before they were released? If he is unable to tell us today, will he commit to publishing that data in his response to the Written Questions I tabled on this very point on 22 October?

[The Parliamentary Under-Secretary of State, Ministry of Justice (Lord Lemos) (Lab)]

There are various reasons why individuals who have an electronic monitoring order are not yet tagged, including not being at their address when officers arrive or being within in the contractual 48-hour period for installation. They may have been recalled, or the tag may have been tampered with or cut off. I do not agree with the noble and learned Lord that the earned progression model and release under it are likely to have increased those numbers. The earned progression model has been planned and releases under that are different—I make this point every time I speak on this at the Dispatch Box, and it is a really important point. It is not the same as the emergency early release schemes introduced under the last Government and at the beginning of this one. It is a planned process happening in 10 tranches. We made sure that the tag resources were available through Serco, so I do not agree with that. On the question of data, we will publish data on tagging in the normal way.

[Lord Marks of Henley-on-Thames (LD)]

My Lords, the Government now seem to recognise that home tagging after a prisoner’s release has serious problems. First, until released offenders can be tagged at home, they can be a frightening menace to their victims. Secondly, if they have no stable home, they can prove very difficult to tag at all. Yesterday in the other place, Minister McKinnell told my honourable friend Jess Brown-Fuller MP that tagging at prisons before release, so-called tagging at source, was being ramped up. She welcomed a suggestion from Dame Emily Thornberry MP that prison officers should be trained to fit the tags and were willing to take such training and do so. Tagging at source is obviously a better and, I suggest, a cheaper system and one wonders therefore why home tagging was ever an option. The Government have an extra £100 million earmarked for tagging. Why can tagging at source not be organised almost at once? Why the delay?

[Lord Lemos (Lab)]

Home tagging was instituted under the previous Government and is part of the Serco contract, as we have discussed before. The Government agree that tagging at source is the right approach, and that is what Minister McKinnell said yesterday. We are rolling that out and are doing it in an orderly way. We are receiving a great deal of co-operation from prison staff as we go about that. That is the right answer, and that is what we are going to do. On this whole question of tagging, I think all noble Lords who work in this area know that tagging will be an increasingly important part of the criminal justice system. The way we go about it will evolve and, exactly as the noble Lord, Lord Marks, said, tagging at source is the future and we will get there as soon as possible.

[The Lord Bishop of Gloucester]

I remain concerned that the problem is constantly being framed as a lack of prison capacity, but there needs be a very different narrative which includes a major focus on reducing reoffending and addressing what underlies so much offending. Can the Minister say what is being done to ensure that, alongside tagging, the Probation Service is properly funded, resourced and supported to address the issues that underlie the offending of those who are tagged?

[Lord Lemos (Lab)]

I hesitate to correct the right reverend Prelate—I know that is not good form, especially not coming from me—but I did not frame the problem as part of the prison capacity problem. I framed the issues around tagging as being related to our earned progression model. This gives me an opportunity to advertise the presentation I have arranged for noble Lords on 23 November on the earned progression model. On reducing reoffending, I should have declared my interest at the beginning, which is that I was the lead non-executive director and chair of the agency board of HMPPS until 2025. During that time, in relation to one of the key aspects that the right reverend Prelate knows is part of reducing reoffending—accommodation—we secured accommodation for 35,000 people leaving prison. That is a substantial contribution to reducing reoffending.

[Lord Hogan-Howe (CB)]

My Lords, the Government have the right idea about tagging, and I support the Minister in saying that. However, I think there are serious problems in the operation of it now and the ambition for it for the future. First of all, tags are not being fitted, and if they are not fitted at source, they never get fitted. Probably more important is the future, with geolocation for devices, which allows people to be excluded from areas, as well as to be kept within areas, and sobriety tagging, which stops people drinking when drink is the aggravating factor in their offending pattern. There is no strategy as to how this is going to develop in the future. There is no real connection to the police or, as has already been said, the Probation Service. The current system means that an email goes from Serco or whichever commercial entity it is, and within the next few days, the police might get some information about a rapist who breached the curfew around the rape. That could all be done digitally immediately. I think the ambition is incredibly good—

[Baroness in Waiting/Government Whip (Baroness Hyde of Bemerton) (Lab)]

I encourage the noble Lord to move to his question, please.

[Lord Hogan-Howe (CB)]

I am getting there.

[Baroness Hyde of Bemerton (Lab)]

I remind noble Lords that there are only 10 minutes for this session.

[Lord Hogan-Howe (CB)]

I know, but if the noble Baroness keeps interrupting, I will not get there.

[Noble Lords]

Oh!

[Lord Hogan-Howe (CB)]

My question is: what are the Government’s ambition and strategy for rolling out tags in the future? I have not seen one.

[Lord Lemos (Lab)]

I disagreed with the right reverend Prelate and now I am going to disagree with the policeman—former policeman. I do not accept that characterisation. The situation on the specific question that the noble Lord raises about knowing where tagged people are is that by Christmas, because we are rolling out our plan, probation officers in every region will know the whereabouts of people on tags within 10 minutes, so the situation that he describes should not arise. I do not accept that there is no plan. I have already said that this is an important part of the future. It is an important part, for example, of the work that we are doing on domestic abuse in relation to alcohol tags. GPS tagging is improving. This will continue and it is extremely significant.

[Lord Woodley (Lab)]

My Lords, the Minister knows only too well that the private sector is due to pocket an extra £100 million as a consequence of the expansion of the tagging service. As I said only last week, it is on its knees. It is very difficult to see how we can improve the situation when we have unacceptable strings on the table for the unions to accept. Therefore, does the Minister agree that HMPPS needs to remove these strings and give the staff a bigger slice of this £700 million pie, as opposed to their going on strike, which we do not need at all in this country?

[Lord Lemos (Lab)]

I am sure that my noble friend—my good friend—will understand that I do not want to comment on the negotiations that are under way, but I will say this: the staff of HMPPS have risen to challenges that many of us would find impossible. I pay tribute to them and they deserve credit. As we ask more and more of them, we will of course work with them to ensure that they are motivated and properly rewarded.

[Lord Bellingham (Con)]

My Lords, can the Minister tell the House how many of the 5,000-plus prisoners released have reoffended since this scheme started in its latest format?

[Lord Lemos (Lab)]

The figures on tagging, as I have said, will be released in the normal way. We publish stats on reoffending and will continue to do so.

[Lord Foster of Bath (LD)]

My Lords, the Minister tells us very clearly that Serco has been meeting its contract requirement since March. However, the Chief Inspector of Prisons points out that that contract requires specification of attempting to tag rather than succeeding in tagging; that 45% of GPS tags and 40% of alcohol tags have been fitted late; that one in five people has had to wait up to two weeks for a tag; and that, amazingly, one in 10 has waited up to five months for their tag. If that is contract specification, is there not something dreadfully wrong with the contract?

[Lord Lemos (Lab)]

The noble Lord is an expert on this; he chairs the committee and quoted all those statistics at me without reading his notes. He knows, as I do, that what we inherited was a tagging system in crisis. What we have done is to put the arrangements with Serco on a better footing. I do not deny for a moment that there are still problems. We have access to its performance data, and the situation is being better managed than it was before, but there is still some way to go.

Health Bill

Wednesday 28th October 2026 Lords Chamber

Committee (1st Day)

Northern Ireland, Scottish and Welsh legislative consent sought. Relevant document: 12th Report from the Delegated Powers Committee.

16:01

Clause 1 agreed.

Clause 2: Transfer schemes in connection with abolition of NHS England

Amendment 1

Moved by

[Baroness Merron]

1: Clause 2, page 1, line 16, at end insert—
“(1A) The Secretary of State may not make a transfer scheme transferring anything to—(a) a Scottish public body, without the consent of the Scottish Ministers;(b) a Welsh public body, without the consent of the Welsh Ministers;(c) a Northern Ireland public body, without the consent of a Northern Ireland department.”Member's explanatory statement
This amendment would require the Secretary of State to seek the consent of the appropriate devolved nation before making a transfer scheme which transferred property, rights and liabilities from NHS England to a Scottish public body, Welsh public body or Northern Ireland public body.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, as I said at Second Reading, the abolition of NHS England is being taken forward with the interests of patients firmly at its core. It will provide greater clarity for the system. It will restore democratic accountability and free up resources to be reinvested in the front line. It will also bring greater clarity about where responsibility lies, ensuring that Ministers are accountable for national decisions while devolving more power to local NHS organisations. Patients will benefit from faster and clearer decision-making, with less duplication and red tape, with staff being allowed to spend less time navigating bureaucracy and more time focused on care and delivery.

I will address the government amendments to Clauses 2 and 28 together. Amendment 1 and consequential Amendments 2 and 3 make additions to Clause 2, which empowers the Secretary of State to establish transfer schemes. These clauses provide a structured and transparent means of moving property, staff, rights and liabilities from NHS England to the Department of Health and Social Care, integrated care boards and other relevant bodies.

Following engagement with the devolved Governments, these amendments have been tabled to require the consent of the relevant devolved Government should a transfer be made to a Welsh, Scottish or Northern Ireland public body. Amendment 1 does not change the purpose of Clause 2 but provides assurance to devolved Governments that any transfers to their bodies can take place only with their agreement. I emphasise that there are currently no plans for transfers to be made to devolved Governments’ public bodies, but this amendment provides a proportionate safeguard if such circumstances arise in the future.

Likewise, Amendments 103 and 104 are technical amendments to Clause 28, this time in response to engagement with the Welsh Government. They make clear the territorial limit of the clause to ensure it could not be used to establish, or delegate functions to, a Welsh special health authority. I believe these to be sensible and proportionate amendments, and I beg to move Amendment 1.

[Baroness Finlay of Llandaff (CB)]

My Lords, I welcome the Minister’s discussions with the devolved Governments and her saying that nothing is going to be potentially imposed on them, particularly having had those discussions. But can she clarify what will happen to some of the prevention agendas that have been in place—such as the Couch to 5K programme, for which I understand no outcomes have been collected, but which has been part of NHSE and the department’s promotion of exercise—and whether these programmes will be increasingly promoted across England as part of the prevention agenda, and in discussion with the devolved Governments, so that we get consistency in prevention across the United Kingdom?

[Baroness Pidgeon (LD)]

My Lords, we welcome these Government amendments, which ensure that the devolved Administrations’ boundaries are protected and that there is proper consultation and agreement. But devolution must be integral to any legislation from the start, rather than an afterthought. Granted, there has been consultation with the devolved Governments, but these amendments were tabled very late and this is a worrying sign. It is an indication that aspects of the reorganisation and its governance implications had not been properly thought through at the start—through the lens of the devolved Administrations, rather than simply through that of Whitehall and civil servants centrally. The Minister’s words have provided some assurance, and I look forward to the devolved Administrations being at the start and the heart of legislation such as this in the future, rather than an add-on at a late stage.

[Earl Howe (Con)]

My Lords, it is a pleasure to begin our Committee consideration of the Health Bill, and I look forward to the discussions over the coming days. I am grateful to the Minister and to the Government for bringing forward these amendments, which we understand to be principally technical in nature, although there are questions we shall want to ask in later groups about cross-border patient referrals and related issues. We welcome the clarification these amendments provide regarding the consent of the devolved Administrations and the exercise of powers by devolved health bodies, and we are content to support them.

I hope the Committee will allow me to take this opportunity to acknowledge the letter sent by the Minister this morning concerning Healthwatch. Noble Lords across the House will welcome the Government’s decision not to proceed with its abolition, and I am grateful to the Minister for listening to the concerns raised in this House and elsewhere. This is a very positive example of the Government engaging constructively with the scrutiny of this Bill and showing a willingness to reconsider their proposals where legitimate concerns have been raised. That is precisely the spirit in which I hope we can continue our consideration of this legislation, and I welcome the approach the Government have taken on this occasion. I look forward to the Minister’s response.

[Baroness Merron (Lab)]

My Lords, I am grateful for this brief but important debate, and in particular for the support for these amendments. As the noble Earl, Lord Howe, says, they are technical amendments. I say to the noble Baroness, Lady Pidgeon, that this is absolutely nothing to be worried about: we work closely with the devolved Governments, and this is an extra layer of reassurance to them that we felt was helpful, because it is what they sought. These technical amendments are brought forward not as an afterthought but because that is what conversations have led us to think is the right thing to do. I know they very much welcome this, and I am grateful for their assistance.

I hear what the noble Earl, Lord Howe, said about the letter I sent out and the announcement in respect of Healthwatch. I am most grateful to noble Lords for their engagement as we have approached this point in the Bill. As the noble Earl acknowledged, we are always keen to listen. We cannot always do exactly what every noble Lord would want, but I am glad that the noble Earl welcomes the way in which the Secretary of State and the Prime Minister have approached this.

On the point raised by the noble Baroness, Lady Finlay —who also gave her support—about particular programmes, I am very happy to look into that. However, as I have set out, we intend for the programmes to which we are committed to be transferred to the department. What happens in the longer term on the prevention agenda is another consideration. We work very closely with the devolved Administrations on prevention, but, ultimately, healthcare is a devolved matter. I commend the amendment to the Committee.

Amendment 1 agreed.

Amendments 2 and 3

Moved by

[Baroness Merron]

2: Clause 2, page 2, line 14, leave out subsection (4)
Member’s explanatory statement
This is consequential on my amendment to Clause 2, page 2, line 21.

3: Clause 2, page 2, line 21, at end insert—
“(7) In this section—“Northern Ireland public body” means a public body whose functions are exercisable only or mainly in or as regards Northern Ireland and relate only or mainly to transferred matters (within the meaning of the Northern Ireland Act 1998);“Scottish public body” means a body that is a Scottish public authority with mixed functions or no reserved functions (within the meaning of the Scotland Act 1998);“the TUPE regulations” means the Transfer of Undertakings (Protection of Employment) Regulations 2006 (S.I. 2006/246);“Welsh public body” means a body that is a devolved Welsh authority as defined by section 157A of the Government of Wales Act 2006.”Member’s explanatory statement
This is consequential on my amendment to clause 2, page 1, line 16.

Amendments 2 and 3 agreed.

Clause 2, as amended, agreed.

Clause 3 agreed.

Amendment 4

Moved by

[Earl Howe]

4: After Clause 3, insert the following new Clause—
“Abolition of NHS England: transition plan(1) The Secretary of State must prepare and publish a transition plan in relation to the abolition of NHS England.(2) The transition plan must set out—(a) the objectives which the abolition of NHS England is intended to achieve;(b) the arrangements and timetable for transferring the functions, property, rights and liabilities of NHS England;(c) the bodies to which those functions, property, rights and liabilities are expected to be transferred;(d) the estimated gross costs associated with the abolition of NHS England and the implementation of the arrangements mentioned in paragraph (b); (e) the estimated costs of redundancies, voluntary exits, pension liabilities and other staff-related payments arising from—(i) the abolition of NHS England,(ii) the restructuring of the Department of Health and Social Care,(iii) changes affecting integrated care boards, and(iv) changes affecting commissioning support units;(f) the estimated costs associated with—(i) the transfer, retention or disposal of property,(ii) the transfer, variation or termination of contracts,(iii) the transfer of information technology, data, records and other systems,(iv) the establishment or modification of governance and accountability arrangements,(v) the recruitment and training of staff,(vi) the retention or replacement of specialist staff and expertise,(vii) consultancy and other external professional services, and(viii) any other activity required to implement the abolition;(g) the estimated recurring annual savings expected to arise from the abolition of NHS England; (h) the extent to which the savings mentioned in paragraph (g) are expected to constitute cash-releasing savings;(i) the methodology, assumptions and baseline against which the costs and savings mentioned in this subsection are to be calculated;(j) the financial year in which the total cumulative savings arising from the abolition of NHS England are expected to exceed the total cumulative costs of implementing that abolition;(k) the existing departmental, health service or other budgets from which transition costs are to be met;(l) the effect which meeting transition costs from the budgets identified under paragraph (k) is expected to have on—(i) the provision of health services,(ii) planned capital and technology expenditure,(iii) integrated care boards,(iv) workforce budgets, and(v) other departmental programmes;(m) the amount of any savings expected to be made available for the provision of front-line health services and the arrangements by which those savings are to be identified, transferred and monitored;(n) the principal clinical, financial and operational risks associated with the transition;(o) the measures to be taken to secure the continuity of services during the transition;(p) the measures to be taken to identify, retain and transfer staff with specialist knowledge or expertise;(q) the arrangements for the transfer and continued operation of nationally significant services, contracts, information systems and corporate holdings;(r) the measures by which the Secretary of State will assess whether the objectives mentioned in paragraph (a) have been achieved.(3) The estimates contained in the transition plan must distinguish between—(a) one-off transition costs,(b) recurring expenditure,(c) gross savings,(d) net savings, (e) cash-releasing savings, and(f) non-cashable efficiencies or avoided future costs.(4) The Secretary of State must arrange for the transition plan, including its financial estimates, methodology and assumptions, to be reviewed by an independent person with experience of public-sector finance, organisational restructuring or health service administration.(5) A person carrying out a review under subsection (4) must assess—(a) whether the estimates in the transition plan are reasonable,(b) whether the plan identifies the full costs of implementation,(c) whether the methodology and assumptions used to calculate costs and savings are reasonable and have been applied consistently,(d) whether the distinction between gross, net and cash-releasing savings is clear and supportable,(e) whether the expected break-even date is supported by the available evidence, and (f) whether the arrangements for managing risks and maintaining operational continuity are adequate.(6) The person carrying out the review must prepare a report setting out the conclusions of the review.(7) The Secretary of State must publish, alongside the transition plan—(a) the report prepared under subsection (6),(b) the name of the person who carried out the review,(c) a statement of that person’s relevant experience and qualifications,(d) a description of the process by which that person was appointed, and(e) a declaration of any interests which might reasonably be thought to affect that person’s independence.(8) The Secretary of State must lay the transition plan and the report prepared under subsection (6) before Parliament.(9) The Secretary of State must comply with subsections (1) to (8) before making regulations bringing section 1 or 2 into force.(10) In this section—“cash-releasing savings” means a reduction in expenditure which releases resources that may be reallocated without reducing the level or quality of services provided;“front-line health services” means services provided directly for the prevention, diagnosis or treatment of illness, or for the care of patients;“NHS England” means the National Health Service Commissioning Board.”Member’s explanatory statement
This new clause would require the Secretary of State to publish an independently reviewed transition plan before commencing the abolition of NHS England.

[Earl Howe (Con)]

My Lords, in moving Amendment 4, I express my appreciation to the noble Lord, Lord Kakkar, for adding his name to it.

I well recognise that Members of the Committee may be taken aback by the monumental size of this amendment, but its size is, to a very real extent, its point. The main raison d’être of the Bill—indeed, its starting point—is the abolition of NHS England and the reorganisation and reallocation of its functions and responsibilities. That is as monumental a process as it is possible to imagine, involving, as it does, just about every branch of the health service, from commissioners to providers to the training of doctors. More than that, the momentous decision to abolish NHS England came largely unheralded. The report from the noble Lord, Lord Darzi, on the state of the NHS, published in 2024, stated in terms that another top-down reorganisation of the NHS was the last thing that it needed. It seemed quite clear that the noble Lord, Lord Darzi, thought there were other ways of tackling the various issues in the NHS that he had identified.

Whether or not the decision to abolish was taken in haste, I am afraid that what has happened since has been a cause for criticism. The abolition was announced without any explanation given to NHS staff about what the Government were seeking to achieve, and without any provision for redundancy funding. Planning for how the new department would look took months to get off the ground. Even now, some 18 months after the decision was announced, there is still a fog of uncertainty around where a number of commissioning responsibilities are going to sit—whether they will be devolved to ICBs or transferred to the department. Some functions, especially regulation, will need to sit centrally but will require independence from ministerial control; others will need to be devolved nearer to the bodies responsible for delivering patient outcomes. There is, as yet, no clarity on the complete picture.

16:15

This matters, not just on a theoretical level but on a very practical one. One example is specialised commissioning. What is the appropriate footprint for commissioning and delivering services for rare or very rare conditions? We still do not know which of the current 170 specialised services will be commissioned centrally and which by ICBs, or what the logical basis for such decisions ought to be. Hand in hand with that, we still do not know whether there will within ICBs be sufficient capacity and expertise to fulfil the statutory duties that they are given to deliver those services. Up to now, the process of delegation to ICBs by NHS England has progressed unevenly across the country. At a time when ICBs are being told to shed large numbers of staff, the risks around this whole area of reform do not need spelling out.

The Government have said that abolishing NHS England will eliminate duplication, reduce bureaucracy and deliver savings. On a theoretical level, that is language that I am sure we all understand. However, what does it mean in practice? We hear that the abolition of NHS England will deliver savings of around £1 billion a year by the end of this Parliament. However, the Explanatory Notes to the Bill estimate that the cost of redundancy exits across NHS England, the department, integrated care boards and commissioning support units will be between £1 billion and £1.3 billion. That is an enormous sum of money to spend on restructuring before we have seen any of the promised savings.

The figures raise some fairly obvious questions. First, what is the full cost of the reorganisation? The Explanatory Notes identify the estimated costs of redundancy exits but say little or nothing about the wider costs of transferring functions, replacing systems, managing contracts, retaining specialist expertise and establishing new governance arrangements. For example, we are in the dark about which policy teams are to be reduced or even removed, and nor do we know whether there will be more or fewer commissioning support units than there are at the moment. Are all these costs included in the Government’s estimates, and can the Minister confirm whether the original estimates of costs and savings remain accurate?

Secondly, when do the Government expect the reorganisation to pay for itself? There is an important distinction between achieving annual savings of £1 billion at some point in the future and having actually recovered the substantial sums spent on delivering those savings. When will the cumulative savings exceed the cumulative costs of the transition, and when will those savings become available for reinvestment in front-line services?

Thirdly, where is the money to pay for all this coming from? Many have expressed the fear that the costs of this reorganisation can be met only at the expense of front-line services and/or planned capital investment and/or improvements in technology—or even to the detriment of the research or education budgets. Is the Minister willing to set out detailed answers to these questions in a letter to be placed in the Library, so that, between now and Report, noble Lords can gain a fuller picture of what is planned?

The health service is an extraordinarily complex and interconnected system. When we remove or relocate one part of that system, we need to be certain that we understand what depends upon it. The transfer of functions from NHS England will involve not only changes to governance and accountability but the movement of staff, contracts, information systems and specialist expertise between organisations. These are substantial undertakings in their own right and they will need to be managed while the NHS continues to deliver services to millions of patients. That process carries risks to the stability of patient services. That is why this amendment would require the Government to set out not only the financial implications of the transition but the principal clinical and operational risks, the measures that will be taken to maintain continuity, and the arrangements for retaining and transferring specialist staff.

Exactly how will the Government ensure that nationally important services, contracts, information systems and specialist functions continue to operate without interruption as responsibilities are transferred away from NHS England? Who will be responsible on a day-to-day level for managing these risks? In the final analysis, the risks involved in all of this are risks to patients. Long-term savings of £1 billion a year are certainly worth having, but the looked-for benefits of this major reform need to be balanced against the degree of risk that the Government are now placing on the lives and the health of patients in the course of achieving those benefits. We are at a moment when waiting times are already high, hospital wards are full and services everywhere are stretched. I can only express the hope on behalf of us all that Ministers and the good and capable officials, who are doubtless doing their utmost to deliver these reforms in one piece, prove more than equal to the huge task that they have been set. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome the amendment from the noble Earl, Lord Howe, because it enables us to go to the core of what this legislation is all about. Light-touch amendment it is not, but I think it goes to the heart of what we need to talk about.

As I said at Second Reading, I really welcome bringing NHS England essentially into the department. It restores ministerial accountability to Parliament and, for a £200 billion service, that is very important. Essentially, it seems to me that we are going back to a 1948 Bevanite model of the NHS. Of course, we do not recall his dictum, but it is very famous—that when a bucket of slops is kicked over by a maid in hospital in Tredegar, its echo should sound in the corridors of Whitehall. Bevan also said at the time, because of course he backed off Morrison, who wanted local government to control the NHS, that he wanted lots of decisions to be made locally through the hospital management committees and regional hospital boards that were set up. Of course, the moment it started, the Ministry of Health, as it then was, started to issue circular after circular. That is perhaps an inevitability of the way you get there, when you have a national health service funded simply through taxation.

There are some genuine issues around the relationship between the centre and the local National Health Service which we need to tease out. We had a round table at which the chief executive of the NHS Alliance spoke about the concern that the alliance has that integrated care boards will find that their room for manoeuvre is very limited. One response to that is that ICBs’ accountability was solely going to be to the centre. The Government’s decision to keep Healthwatch is very important in terms of having more local accountability—that is why it is so welcome. I know that noble Lords are concerned about Ministers taking over responsibility for the appointment of chairs and non-executives, but I think that we should also keep councils of governors of foundation trusts. They are local people, elected by members of those trusts, who do the current round of appointments. We will come to this later on in our debate on Clause 30. I am really looking for the Government to look at this again.

There are some real issues about the future relationship of the centre to the locality. I commend the brief that we have had from the King’s Fund, which poses some key questions. What should the boundary be between legitimate national oversight and routine operational management? What would prevent this broad power becoming a mechanism for day-to-day management from Whitehall? How will you deal with bottlenecks, and the practical risk that moving a large number of functions and decisions towards the Secretary of State could slow the NHS down rather than speed decisions up, particularly around the appointment of chairs and non-executives? Which of the Secretary of State’s most consequential intervention powers will be subject to intervention, advice or scrutiny? In what circumstances would Ministers expect to intervene in local service reconfiguration? What safeguards will ensure decisions that are often best made locally and on clinical grounds? How is the greater role for local government and mayors to operate alongside stronger central powers and require the Secretary of State to have regard to local decision-making? What statutory safeguards will there be in relation to the powers of the Secretary of State to appoint, suspend or remove the chair and other non-executive directors? For the Secretary of State’s most consequential intervention powers, is there a case for putting relevant decision-making criteria on the face of the Bill?

I do not know the answer to that, but I think that, by Report, it would be helpful if my noble friend could explain in a little detail how the Government think the new arrangements are going to work and how you will prevent unnecessary micromanagement from the centre.

[Lord Kakkar (CB)]

My Lords, I have added my name to the amendment in the name of the noble Lord, Lord Kamall, and the noble Earl, Lord Howe. In so doing, I remind noble Lords of my own declared interests, as chairman of King’s Health Partners and the King’s Fund.

I believe this to be a very important amendment and fundamental to the purpose of the Bill. Your Lordships’ House has taken, quite appropriately, the explanation, reassurances and logic behind the abolition of NHS England provided by the Minister at Second Reading. As the report commissioned by His Majesty’s Government identified very clearly, further reorganisation on a major scale of the NHS should have, at all costs, been avoided, as noted by the noble Earl, Lord Howe. There are clearly in the Government’s mind important reasons why this reorganisation must proceed, and it is important for your Lordships to respect that. It is a fundamental element of His Majesty’s Government’s policy.

However, in proceeding down this route, the other side of the coin is that His Majesty’s Government must be clear, and provide reassurance about the implications, both in the period of transition and thereafter, with regard to the important functions that have sat in NHS England and will now be brought back under central Secretary of State control. We have heard a number of those, and it would be interesting if the Minister could explain to your Lordships how the transitional arrangements that are going to be applied will reflect the ultimate structure of the newly defined function for delivering NHS England within the Department of Health and Social Care. For instance, how will the Secretary of State powers be exercised? What degree of delegation is there going to be? How will that be reflected in the transitional arrangements?

In terms of the broader government agenda with regard to devolution to a local level, is it consistent to have brought all these powers centrally and then expect, within a reasonable time period, proper devolved scrutiny and determination of local health needs to be reflected in the delivery of the NHS? What will be the arrangements for the operational management of the NHS in the intervening period between now and the final adoption of all measures? How is that going to work? What is happening at the moment? Is the Minister content that in the many issues on which there is, or has been, granular oversight within NHS England and its regional structures, that that kind of oversight is being, and will be, delivered in these transitional arrangements?

16:30

When there are crises, or when day-to-day delivery of the NHS at a local level starts to falter, there is a need for clarity and an ability to intervene. As we have heard from the noble Earl, Lord Howe, ultimately all these changes will impact patients. If we are not clear about how these arrangements are secure, how they will be governed and how those responsible will be held accountable, then we will be sanctioning potential situations in which patients may well be put at risk of harm. At the very least, when the application of valuable resources may not be applied in the fashion most efficient, patients may wait longer and be denied important interventions. The important progress in improving the delivery of healthcare and clinical outcomes, to which His Majesty’s Government are so strongly committed, will be inadvertently undermined through a programme of transition and reform that has not been properly laid out and described in organisational terms.

Beyond that, as the noble Earl has identified, there is the important question of the financial arrangements. At Second Reading, I noted that in 38 of the 40 years prior to 2020, the NHS failed to deliver services within its pre-agreed budget for the specific financial year in question. It usually overspent by about 1.3%. That was a historic reflection; it may be perfectly reasonable and there may be completely justified explanations. However, we now find ourselves in an economic and fiscal situation where it is going to be impossible for the Government to continue to increase settlements year on year for NHS expenditure.

Therefore, it is very important for us to understand how the costs associated with this reform will be met. Are they being met from current budgets? Are additional funds expected to meet the costs of delivering these reforms and the transitional arrangements before savings accumulate? If there are no additional funds available, will the funds be drawn, as we have heard, from front-line clinical services or from the education and training budget, which is often vulnerable, particularly since a previous reform has taken Health Education England into NHS England and that separation no longer exists? Will it undermine the capacity for the NHS to continue to deliver on its important research and innovation agenda? That may be seen as a part of the budget that might be sacrificed for a short period while arrangements are made to deliver this transformation and reform.

These are all fundamental questions. The answer to all of them may be no and there is no risk to any of this. That would be very reassuring, but it is something we need to understand. None of these questions should be taken as opposition to the abolition of NHS England. As I said earlier, that decision has been taken. The purpose of this Committee and the opportunity afforded by the Bill is to ask the questions that attend an absolute guarantee that the arrangements to be put in place will serve the purpose as defined and that those arrangements—in particular, these transitional arrangements—will serve the opportunity to secure the more fundamental longer-term questions about the powers of the Secretary of State, the opportunity for delegation, where operational responsibility in the NHS will ultimately lie, how this reform resonates with the devolution agenda and what the mechanism will be for the different elements of the newly organised NHS, under direct supervision of the Department of Health and Social Care, to function, be it centrally, regionally or at local level.

[Lord Stevens of Birmingham (CB)]

My Lords, I support the amendment in the names of the noble Earl, Lord Howe, the noble Lord, Lord Kakkar, and other noble Lords, because it draws attention to the fact that we are on the cusp of a huge reorganisation, yet there is a remarkable lack of clarity as to how it is going to be given effect.

First, can the Minister confirm to the Committee that it is still the Government’s intention that NHS England will be abolished on 1 April? There is a groundswell of discussion across the centre of government and the NHS which suggests that that is looking to be an increasingly impractical date. Can she confirm the Government’s concrete intentions on that? If she tells us that it is still going to happen on 1 April, then it ought to be entirely possible for the Government to accede to the amendment put forward by the noble Earl, Lord Howe, because, clearly, one could not, a mere matter of months away, be proceeding without already having the information that the amendment requests.

Dr Penny Dash, the outgoing chair of NHS England, was before the Commons Health and Social Care Committee five months ago, which was also exploring the question before us now. Dr Dash said that

“in a few weeks’ time a paper will be coming to the transformation oversight board, or whatever we call it, giving more detail”

on these questions. When asked whether the 50% reduction was a hard figure, she said:

“In terms of the NHSE and the DHSC … there was this sense that 50% was the right number to aspire to. The detailed work will get us to the point of determining what the numbers could and should look like”.


If 1 April is really the date, can the Minister tell us what those numbers will look like, whether it is 50% and how it is broken down, as requested in this amendment?

We already have signs that pragmatism is asserting itself in the Department of Health and Social Care, with the decisions on HSSIB and now Healthwatch. Will this be a further example of pragmatism or will the new Secretary of State stick to the plan, which is a perhaps a little half-baked, that she inherited? We already have the most centralised and politicised health service in the industrial world. Going down this path takes us yet further in that direction. If that is what we are going to do, it should at least be done well.

[Lord Lansley (Con)]

My Lords, I support my noble friend in his amendment. I do not want to revisit Second Reading issues, but will make one or two important points. First, along with other noble Lords, I say a big thank you to the Minister for some of the correspondence we have received and the way in which she and the Government have already been listening to the discussions in this House. I hope that we can continue to have a constructive discussion.

I do not entirely share the view of the noble Lord, Lord Kakkar, that the abolition of NHS England is a done deal and we should therefore accept it. It was not a manifesto commitment. Parliament has had no say in this matter. It is all the more important that, as we implement the Government’s intentions into law, we understand what we are doing and how. That is particularly true in so far as there is some speculation whether all these responsibilities will be incorporated into the department—the noble Lord, Lord Hunt of Kings Heath, sees it all as becoming engaged in the department and therefore accessible to Ministers. If many of these responsibilities are to be held in special health authorities outside the department, it is hard for some of us to understand what has been gained in accountability relative to the current situation between the department and NHS England. Of course, Ministers had powers under the previous legislation to exercise accountability over NHS England, not least through the process of a mandate, but often failed effectively to use them—sometimes the use of powers by Ministers is more important than other things.

The key point here is the transition. The Government have put into the legislation that there will be transition schemes, but we need to see what they look like and how the timing works. I recall that the gap between the passing of the 2012 Act and its implementation was almost exactly a year. That further strengthens the force of the questions that the noble Lord, Lord Stevens of Birmingham, just asked. We need to see what that timetable looks like.

From a curiosity point of view, I would be interested to know how these savings will be generated. Noble Lords often say that a great deal of money was spent on the 2012 reforms. The Written Ministerial Statement published on 21 July 2015, at the end of the 2010 to 2015 Parliament, told us what the outcome was: the cost totalled £1.38 billion, a little more than my noble friend Lord Howe said the Government anticipate that the overall cost of this reorganisation will look like, but not much more. By the end of the Parliament, the savings were £6.9 billion in cash. Not least in some of the debates, people tend to remember the cost but not the savings. It would be extremely useful for us to know in advance what is intended to be achieved, because that reorganisation, according to the data published in 2015, arrived in the final financial year of that Parliament at a £2 billion a year reduction in cost. The Government are not even attempting to achieve something as ambitious as that. Let us see what it looks like.

I make one suggestion, to which I hope the Minister will respond. It is not unknown for the National Audit Office to engage in a process of scrutiny not after the event but during the event. This is especially true for major projects. This is a major project, and over the course of the next year it would be good if the department volunteered itself to the National Audit Office for such a process of real-terms scrutiny of the value-for-money effectiveness of this reorganisation.

[Baroness Thornton (Lab)]

My Lords, I thought it would be appropriate for those of us who have been involved in this for the last 15 years or so to join in the debate a little. The noble Lord, Lord Lansley, is quite right: this is about transition. It is about a transition that affects two groups of people: patients and people who work in the NHS.

I am a veteran of the transitions that we have had so far, because I was abolished in 2020. I became a member of my local CCG, which I very much enjoyed serving on, having worked on the 2012 legislation that created it. I then took refuge as a non-executive director in my local hospital. I helped to create our local ICB, which is now being abolished with a super-ICB being created. I feel as if I have been at the governance coalface of the reorganisations for the last 15 years. This is an important debate, and I am in favour of the abolition of NHS England.

I intend to involve myself in Committee mostly with equality, social care, patient records and so on, but I have a question for my noble friend the Minister about the arrangements for the people who will move from NHS England into the department and where they stand right now. Those people are very precious to us, and many of them are very experienced. I would like to know how the TUPE arrangements are progressing, what the dates are for those arrangements and when we are likely to see some documentation about how that will actually happen.

[Baroness Nargund (Lab)]

My Lords, I understand and support the general thrust of this amendment. I have worked in the NHS for nearly 40 years and have worked very closely with NHS England. Having experienced all the transitions that have happened with local health boards, PCTs, CCGs and ICBs, and having worked with CCGs and ICBs across England as a provider and doctor and with NHS England, as I said at Second Reading, I wholeheartedly support the abolition of NHS England. It will cut the bureaucracy and the unnecessary layer. I support the Secretary of State taking back the power to give it away to ICBs where patients are treated. It also fits in with the neighbourhood health plan, because they are best placed to develop and deliver that.

16:45

I thank my noble friend the Minister for organising the round table on Monday. We got some clarity in discussions about ICBs. I was reassured to hear about seven offices being created, representing every region across England, taking control of resources, including for innovation, prevention and population health improvement. I was pleased to hear how these seven offices will function. Having worked with large merged ICBs such as those in the east of England for more than 12 years, I know how well they can function, how they can get more clarity and consistency with protocols and be less of a postcode lottery, as well as having large purchasing power to reduce costs and to deliver more to patients. I welcome all that clarity that was given to us in the round table on Monday on how ICBs jointly will deliver collaboratively for local regions.

However, this is about the transition period. I understand the anxieties and support some of the concerns that noble Lords have raised. We need clarity and a timeline regarding that. I support the abolition and the resources and power being given to ICBs. I have trust in these joint ICB functions to deliver what is needed locally and to work with local authorities and local stakeholders. The plan fits in with the 10-year neighbourhood health plan, reducing local inequalities and addressing wider determinants of health.

Can my noble friend the Minister tell us how the national standards of care, as well as costing and implementation of national tariffs, will be managed during this period? How will they be set, and by what date? How will they be monitored to ensure that the postcode lottery is not widened? How will we make sure that responsibility and accountability are not lost during this period and that the care does not slip for any patient, while expecting it to improve in the long term? Who will oversee these transitions? Who will be accountable for running them smoothly?

I do not believe this needs to be set out in legislation, but it is necessary to get this clarity as well as the timeline. Regarding the population health improvement plans, how will resources be allocated to ensure that inequalities are addressed and that there will be a joint system with local authorities as well as local stakeholders?

[Baroness Manzoor (Con)]

My Lords, I thank the Minister very much. I am absolutely delighted that the Government have listened with regards to Healthwatch and HSSIB, which are two very important legs of the NHS in terms of independence, patient safety and patient voice. I welcome that and thank the Minister; I know that she is also passionate about those areas.

I thank my noble friend Lord Howe and others who have spoken on his amendment. Irrespective of what one feels about NHS England—I will certainly share my views—it is right that there is an operational plan and a transitional plan. No business would move to such a major reorganisation without having such plans and risk assessments, with key performance indicators and clarity around outcomes in relation to budgets and finance.

My key question is that if savings are to be made, when will they made and how will they be reinvested into direct patient care? With all these changes, what does it mean for the patient? How do they benefit, so that we are not just talking round and round to ourselves about reorganisations?

I have been involved with the NHS for nearly over 40 years—the noble Lord, Lord Hunt, and I have been around a long time. I chaired a health authority when I was in my 20s, and I chaired one of the eight regional offices of the NHS. My region was northern and Yorkshire, and we had a budget of £3.5 billion. I have some experience of transformation and of the difficulties, challenges and risks that will be involved. If we do not have these plans or clarity, things will go wrong. That will adversely affect patient care, when trying to improve patient care is what the Bill is really about.

I do not like to see lots of duplication in services. I like direct and simplified governance structures in the NHS. We had them when we had the regional offices. I recollect—it was a Labour Government at that time—that the eight regional chairs rocked up to the Department of Health, I think quarterly although the memory has faded a bit, and sat down with the Secretary of State, the Permanent Secretaries and the chief executive of the NHS Executive. We went round to find out what the finances were within our regions, which hospitals were performing well and which were not, and where there were real issues about waiting lists. It really concentrated the mind. Then we went back and fed it to all the 60 or 80 chairmen within our regions and their respective chief executives. I am not too worried and concerned that there will be a lot of haters, but we must have very clear plans to enable this to happen.

Last but not least, I want to talk about the governance structures; I mentioned them in my speech previously. If we do not have clarity around governance structures and accountability, we really will not deliver. If there is one plea that I can make, can it be that? I totally support the amendment tabled by my noble friend Lord Howe.

[Baroness Gerada (CB)]

My Lords, one of the people who I have most admired over the years is the American paediatrician, Professor Don Berwick—some of your Lordships may know him—who is an international expert on healthcare and a great advocate of the NHS. In fact, he led the Mid Staffs review in 2013. In the States, he led Medicare and Medicaid under President Obama. It always struck me that Don Berwick wrote us a birthday card on the NHS’s 60th birthday. It was a long card and I urge your Lordships to read it one day. He offered a simple prescription for the NHS: “Stop restructuring”. He warned that successive reorganisations drained the workforce’s “energy and confidence” and argued that stability makes improvement easier. Does the Minister agree that his advice would be well taken?

[Lord Mawson (CB)]

My Lords, I welcome this debate and I certainly support the amendment. I am encouraged by the letter that we received today that there is an open mind within government and a proper discussion taking place about these very important issues. I am a practitioner, as many of your Lordships know, and we are involved in trying to build some of this new health infrastructure around the country. Indeed, today I have been involved in quite an exciting conversation about a health innovation campus in Huddersfield that we are supporting, which has major implications for this Government’s direction of travel—a lot of which I support—around place, collaboration and other things that the Prime Minister has talked about.

However, we are also in touch at the front end with what is actually happening on the ground, and the word I keep hearing from colleagues across the country is “chaotic”, which is a worrying word to be hearing. Therefore, this debate and the detail that is being discussed today really matter for the NHS, for patients and for those of us who are trying to build this infrastructure. Therefore, I am encouraged that the Minister is starting off in an open, transparent and conversational manner in Committee. It is very helpful.

One of my concerns about the changes taking place at the moment is that there does not seem to be a clear vision about prevention. Those of us who have been involved in this space—in my case, I have been involved in east London, and now nationally, for over 40 years—know that on the ground, in very challenging communities, the real determinants of health often have nothing to do with doctors. If you asked our GPs in Bromley-by-Bow, they would tell you that a person getting a job does more for a person’s health than anything to do with doctors. That is why, in Bromley-by-Bow, we ended up building 97 businesses with local people, because we got real about the social determinants of health. It is about whether you have a decent home that is not damp. It is why we built a housing company, which now has 10,000 properties and owns 34% of the land in Poplar. It is to do with whether your relationships in your family are in a good place and whether you feel part of a community—all these things. The numbers that people far cleverer than me come up with say that the impact of all this is 70% to 80%.

I am not clear, with this real opportunity to reform the NHS in this century and with the things we now know, what this Government are saying about the prevention agenda and how clearly they are or are not joining the dots around the social determinants. Part of this conversation is really important, but part of it needs to be about the prevention agenda. As we work our way through Committee, we need far more clarity about what that will mean in practice and in detail in communities across this country.

[Baroness Harding of Winscombe (Con)]

My Lords, it is a privilege to follow the noble Lord, Lord Mawson, and the noble Baroness, Lady Gerada, who between them have many decades more experience than I do of NHS and health and care reorganisation. I have only one major experience from the inside: the last time we were debating the restructuring of the NHS in 2021-22. At the time, as someone from the private sector, I was somewhat surprised to discover that the NHS got on with the reorganisation before the legislation was passed. It is even odder this time: the NHS has started before the legislation but without a plan itself.

Therefore, I welcome this amendment from my noble friend Lord Howe. It is essential that we understand the plan and the timetable, what it will cost and what benefits it will bring. It really is very straightforward. If that does not exist, the idea that it can be complete by 1 April next year is completely gobsmacking. Maybe I am just an innocent businesswoman who does not understand the ways of the NHS, but it just does not seem right. I think this amendment is basic common sense.

Much as I hear the words of wisdom from Don Berwick, I support merging NHS England with the Department of Health. I saw from the inside, particularly during Covid, how important it is to have clear political accountability. I support the basic premise, but I am very worried that the tendency will be to centralise rather than to push resource out to the regions and local communities. As the noble Lord, Lord Mawson, just said, it is at the local ground level that change really happens.

I am very supportive of seeing fewer people employed in organisations that bear the NHS brand but do not actually treat patients. There are tens of thousands of people who are all trying hard and doing valuable work, but they are a long way away from patients. As we bring NHS England into the department, I would love to see, as part of this amendment, a clear breakdown of the cost savings at the national, regional and local level, so that we have sight of whether we are really pushing accountability, and resource and capability, down to where change will bring the benefits that we all seek.

[Baroness Rafferty (Lab)]

My Lords, I will be brief. I support the point made by my noble friend Lord Hunt that the Minister should reconsider the abolition of governors. I have to declare an interest as a former governor of King’s College Hospital NHS Foundation Trust. I spoke at Second Reading about the value of governors and the extraordinary breadth and depth of feedback and accountability that they provide to trusts. We just ask the Minister to reconsider that decision, for I fear that, if governors are abolished, we will have to find some mechanism to reinvent them.

17:00

[Lord Crisp (CB)]

My Lords, I have been resisting the temptation to get involved in this debate, partly because I was not able to join the Second Reading debate, and I apologise for speaking now, having not done that. I start by making just one point, which is that at the beginning of this century, I was running both the NHS and the Department of Health. I had the two jobs, so I have seen some of what we are talking about from inside. I think some of it was extremely successful. On the point about regional offices, there are some models that I am quite sure can be followed.

The reason I stood up is that the noble Lord, Lord Mawson, spoke about prevention. What I realised when I was running the Department of Health is that, with a hospital management background, I had turned it into the department of the NHS, and we had lost some of our health focus. The future is about health, not just about healthcare. We have to focus not just on prevention but on creating health and the conditions to be healthy. I am not going to get into a Second Reading speech, but I want to ask how the Government are going to preserve the proper role of the Department of Health when it gets all this responsibility for the NHS.

The NHS, on which I speak as a former chief executive, runs 24 hours. You get contacted all the time. How will the important responsibility of leadership for health across government be managed? As the noble Lord, Lord Mawson, said, 80% is about housing, employment and the environment. The health system provides the other 20%, and I have to say it is a vital 20%—if you have a nasty cancer or your leg has just fallen off or something, you need that. My question to the Minister is, how are the Government going to preserve the proper responsibility of the Department of Health for all the health functions, as opposed to the NHS functions?

[Baroness Campbell of Surbiton (CB)]

My Lords, I had not intended to speak in this debate, but I have been listening very closely, and I think what is missing is what happens to people at the grass roots—patients who rely on their ICBs to behave and do the right thing in terms of their care and support. When I heard that NHS England was going to shut down, I have to say that my heart went in my boots. That is because I have been working with certain departments to look at ways that we can deliver NHS personal health budgets, from when they were first conceived to now. There was an awful lot of organisational expertise, memory, support and guidance from what was then NHS England to local ICBs across the country. In doing so, personal health budgets became a good way of delivering personalised care at home for people with complex impairments. I should probably declare an interest because I have been negotiating with my ICB for about 15 years. It is not easy. What I worry about in the transition is that we do not have a plan for what is going to happen to the people in NHS England who have all that expertise, history and know-how in supporting ICBs to deliver their support to complex patients in the community in the future.

I am afraid I am not that positive, because in the last two years, since we heard that ICBs were going to make 50% savings, ICBs have been behaving quite oddly towards people with complex and sometimes expensive care in the community. They are institutionalising them even though they were supported in their own homes quite happily; for example, doing their degrees. They are restricting where you can go with your personal health budget and PA and even whether you can be outside the home, because they have told me that it is unsafe. Something odd has been in the air since we knew that NHS England was going. I believe that there were only four people left in the department supporting those ICBs with their delivery and, quite frankly, they are going backwards. I would be keen to have a plan about what is going to happen when NHS England goes. Who is going to do this work? ICBs need ongoing guidance in this area. They do not have the expertise locally, but someone has to do it.

[Baroness Morgan of Drefelin (Lab)]

My Lords, I want to pick up some of the key points in the amendment regarding what the transition plan should look like and focus on.

I am thinking about the experience of cancer patients post the 2012 changes and what came along with them, which was the abolition of the comprehensive cancer networks that were set up around England to deliver the then cancer plan. There was a vacuum following that change, and it took years to establish the architecture that we now have in place for delivery of the current cancer plan. Given the news that NHS England is being abolished, I am really concerned that the momentum around the delivery of the current cancer plan is being impaired, so the points in Amendment 4 about setting out how the continuity of services during the transition will be maintained are important. My worries are about the cancer plan, how we will drive forward the service improvements set out in it and how all 100 recommendations will be progressed, because that is not the responsibility of any one ICB; it is currently driven forward by NHS England. How are the staff associated with that going to be transferred into the NHS? How do we make sure that there will not be a vacuum? We already had a disappointing delay in the appointment of the chair of the National Cancer Board that has been established.

We really need to make sure that this momentum continues. There is massive consensus around the cancer plan, which we should celebrate. There are 200 different types of cancer, more than 200 different types of cancer charity and many different specialities. One in two of us will get cancer at some stage in our lives. It is a massively important area for the health service, and we need to be confident that the transition will not fall between all the gaps, as it did in 2012, and then take years to re-establish the architecture that we need to deliver the ecosystem of success that we have in UK cancer services.

[Baroness Watkins of Tavistock (CB)]

My Lords, I thank the Minister for the meeting that she has arranged and for the progress we have made, and I hope that we will continue to do that as we debate this issue. However, I too am concerned about the costs and benefits in the timetable that is currently set out.

There are two questions that I want to ask. First, has the strategy—which I firmly believe in; we should move away from NHS England—been looked at against the NHS charter? I ask this because Principle 6 says:

“The NHS is committed to providing best value for taxpayers’ money. It is committed to providing the most effective, fair and sustainable use of finite resources. Public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves”.


How much this is costing and when it will be paid back are fundamental in terms of the charter.

The charter also talks about staff rights, and although I am not working in the health service, I have many friends and colleagues who are. This feeling of uncertainty has been going on for 18 months, and I can say as a mental health nurse that one of the worst things for mental health promotion is uncertainty. This amendment really is important in trying to move us forward on the real timetable. Can the noble Baroness say whether there is, as some rumours are implying, a kind of back-pedalling? Now that we have asked the noble Baroness, Lady Casey, to move forward faster, are we trying to get to a point where we have some of the care service strategy in our mind? What could be worse than making a lot of very capable people redundant, and then needing to re-employ them? The costs to society and the taxpayer would be enormous. I just wanted to make those points, and I welcome what the Minister has to say.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I agree that it is absolutely necessary to have clarity on the transition to the new system, and I add my voice to those noble Lords who have talked about the need for clarity for the staff. Successful reform, which we must have, both for patients and all staff, absolutely depends on retaining the expertise, experience and commitment of the staff. If we expect that commitment, we have to give them some security and knowledge of what will happen to their careers and their families—of whether they are going to be made redundant.

This is of course about the systems and cost, but it is also about the networks—the cancer network mentioned by my noble friend Lady Morgan. It is about the consultants, the doctors and nurses, and the people who keep the hospitals going: the cooks and cleaners, many of whom have been contracted out. Those contracts are bound to change as well. The clarity we are all asking my noble friend the Minister for is critical if we are going to ensure the success of this new enterprise.

[Lord Sentamu (CB)]

My Lords, first, I declare an interest in respect of my work with NHS England. I was appointed chair of the sickle cell and thalassaemia organisation, which was not easy work. We did not know whether the people who were coming to make their representations were from a particular trust or had the authority of the then chief executive of NHS England. It was not an easy job.

17:15

Some people were telling us that they did not have the money, and they did not think we would actually achieve screening for sickle cell. We persisted; we worked hard, and we consulted. Eventually, that was achieved after 12 years of work. I want to thank those doctors, nurses and workers who have been dealing with very, very sick people, because sickle cell disease is a tough one. The steering group handed over the work once the screening was accepted, and the joy I then had was that my daughter had a baby. During her pregnancy, she was tested for whether she was a sickle-cell carrier, and they found out that she was. Would the baby also end up with this? But the day our grand-daughter Abigail was born, there was a simple test, and it came back saying no, she was not a carrier. Years ago, that was not a possibility; so there are many things that the NHS has done.

I took part in the debate on the Bill that created NHS England, and there was exactly the same sort of regurgitation of fears, worries and concerns—“We need to do this”. Yes, there are some good things in Amendment 4, but the best thing to do is not to vote for it. Instead, before Report, the Minister and the people with great expertise in this area should have a conversation to sort things out, rather than leaving questions hanging, even though a particular amendment has been passed. That would be very helpful.

During Covid, I sometimes felt that we did not do a good job when we set up NHS England. The noble Lord, Lord Stevens, spoke with great clarity as the chief executive of NHS England. However, the chief executive of one particular trust seemed almost not to be on the side of those who were anxious about the situation, so that system needs to change. We do not need different executives representing the various bodies; there needs to be coherence. When the noble Lord, Lord Stevens, spoke, you knew that he was speaking for everybody, not a particular trust or chief executive. That leads to absolute chaos. I think that that is what the Government want to abolish. I wish they did not use the word “abolish”, because that always creates a lot of fear. I hope they were actually talking about the transformation of this thing called NHS England.

During our dealings with the NHS, we have had four very serious operations. Those operations were well done—it did not matter what hospital it was. But the number of people in the NHS who are not clinicians, support staff or health workers has grown. There are a huge number of managers, and somebody needs to look at this. There are good things in the amendment of the noble Earl, Lord Howe, but it does not answer the question that we all would like answered.

As we move towards transformation, what are the building blocks that must be put in place? To me, that is the question. People say that if a big thing needed to be done in China, it would say, “We are going to build this hospital here”. China does not suffer from this over-consultation, which often does not deliver the reality. I live in a democracy; I would not want to live in China at all. I live in this country, but this country does not grasp the real problem that needs to be dealt with. Therefore, I hope that the signatories to the amendment will find the time—some noble Lords are very good at this—to work out what the building blocks will be for a good transition.

We have fantastic staff in these lovely hospitals where we have been treated, but they are given a management that I do not think often works. This is the opportunity we have to grasp. We have to deal with it and not be the sort of people who are always very difficult and behave like turkeys that do not want Christmas to come.

[Lord Scriven (LD)]

My Lords, I thank noble Lords who have spoken in this rather revealing debate. I particularly thank the noble Earl, Lord Howe, for introducing this amendment in his normal calm and measured way. Importantly, he has given us all the chance to ask the most basic question of the Bill: where is the plan? It is pleasing that the Minister and the Government have been in listening mode, particularly regarding the Health Services Safety Investigations Body and Healthwatch. I hope that during Committee the Government will continue to listen and make other important changes to the Bill.

At Second Reading, I said the Bill was a power grab. The Nuffield Trust’s October briefing for this Committee puts it more politely. It describes new powers for the Secretary of State as being well beyond those that NHS England holds, which it says enables “more political control” and limits real devolution. The Government are entitled to decide whether they want NHS England’s functions in the department, under political hands. We on these Benches would caution on that, but the Nuffield Trust accepts that some duplication between the department and NHS England is real; the Minister must specify exactly what that duplication is. But if that is the aim, it has to be planned and costed.

I would also caution the noble Lord, Lord Hunt of Kings Heath, and the noble Baroness, Lady Harding, for suggesting that putting NHS England’s functions in the department will bring accountability to the Secretary of State. When we get to Clause 11, we may see that the accountability is missing but the powers are about to be transferred.

Noble Lords will know the architect’s maxim that form follows function, but not here—

[Lord Hunt of Kings Heath (Lab)]

Is the point not that at the moment, parliamentarians can raise issues with Ministers only to be told that something is the responsibility of NHS England? I accept what the noble Lord says about how this is going to work but, ultimately, now the finger is absolutely pointed at Ministers for everything that happens.

[Lord Scriven (LD)]

When we get to Clause 11, the noble Lord, Lord Hunt, will see that some of the powers that the Secretary of State now takes, beyond NHS England, will not come before this Parliament. They will just be at the signature of the Secretary of State’s pen.

In this Bill, form comes first and function will follow in due course. We have the demolition notice but are still to see the drawings of the new structure. Let me say how far behind the Government are. The Nuffield Trust, working with the Institute for Government, compared past public sector reforms and NHS abolitions. It found that the key factors for success are not in place here. The abolition was announced without plans to explain its goals to staff and without redundancy funding, which led to months of delay. Detailed planning for the new department began only in early 2026, almost a year after the announcement. Nuffield’s verdict is that the process has been “poorly handled”.

We are still short of very basic information. At Second Reading and in this Committee, the noble Lord, Lord Stevens, who I admit must know something about running the NHS, pointed out that the costs and benefits in the impact assessment are still marked as “not available”. There are also still a number of questions about the timing of when this reform will come in. We have the Government’s estimates that redundancy exits—across the department and NHS England, ICBs and the commissioning support units—will cost between £1 billion and £1.3 billion, to be met from existing allocations, but we must ask which allocations. Which services pay?

Then there is the timetable. On 15 October the Health Service Journal reported that abolition will have to be formally delayed beyond April 2027 unless decisions on future national structures are made within days. Have those decisions been made? Are staff now aware of where they will be transferred? The new operating model has been waiting for ministerial sign-off for months. Ministers are still weighing whether thousands of staff will go to the department or potentially, as we read, into a new stand-alone agency. This Bill sends nearly every function of NHS England to the Secretary of State, yet the Government have not decided where the people who will perform those functions will sit. The department says that it continues to plan for 1 April 2027, but planning a date is not the same as being able to meet it.

The planned 50% job cuts in the department appear to require moving the large majority of central policy and analytical staff. Or is it about cutting operational staff? As the noble Lord, Lord Crisp, said, we need clarity about which staff and which functions will be in the department. It is not clear that the figure is rested on rigorous assessment of who is needed and why. History tells us how this ends: after previous reforms that moved managers from commissioning bodies, the department consultancy spend peaked at over £600 million a year and the number of managers within five years was higher than going into the reorganisation. I fear that this will be another case of “cut first, rehire later and call it efficiency”.

As the noble Earl, Lord Howe, has said, we need not simply rely on the words of noble Lords in this debate. The Darzi review, commissioned by the Government and updated in May, concluded that a top-down reorganisation of NHS England and ICBs is “neither necessary nor desirable” and added:

“Constant reorganisations are costly and distracting”.


We have had six statutory major reorganisations in 30 years, none with clear evidence that the restructure has brought about improvement. The Government commissioned that review; they should read it and learn from it.

I have six questions for the Minister. When will the target operating model be published, and will that be before Report? Is the latest thinking to put transferred NHS England functions and staff into the department, or will the Government set up a stand-alone body? Will the Government publish a full, costed impact assessment, including benefits, and explain where the £1 billion to £1.3 billion comes from? What are the expected costs of disruption, and how will any further delay be limited? Are the Government confident that the 50% cut will not drive up consultancy spending by the end of this Parliament? If the Government do not accept the amendment from the noble Earl, Lord Howe, will they commit to laying a transition plan before Parliament and before Report? In substance, that is what this amendment is asking for.

We on these Benches are not defenders of the status quo. I started in the NHS in the early 1990s and lived through more reorganisations than I care to count. Every one promised less bureaucracy and a freeing up of the front line; none delivered it. If the Government want to put NHS operational matters into political hands, that is their choice, but they owe this House a plan and then a price and then a Bill, in that order. At present we have a Bill and we are still waiting for the other two. I look forward to the Minister’s reply.

[Baroness Merron (Lab)]

My Lords, I am most grateful to the noble Earl, Lord Howe, for moving this amendment, and to the noble Lord, Lord Kamall, for tabling it. As other noble Lords have observed, it is comprehensive and thorough. It makes the point, which a number of noble Lords have made, about the importance of ensuring that the right processes and assessments are undertaken as we move towards the abolition of NHS England—one of the key things in the Bill. As we are at the beginning of our deliberations, I say to noble Lords that I listen, and have listened, very carefully to the points that are made. I will endeavour to answer a number of points, but I will take some away and write to noble Lords. As ever—and as noble Lords will recall from previous Bills—those letters will be available to all Peers, because I want to do justice to those points.

17:30

First, I will address the amendment, which is the key point here. We agree on the importance of robust financial oversight throughout this transition—as noble Lords are rightly calling for—including understanding cost savings and overall value for money. My reflection is that this transition—the noble and right reverend Lord, Lord Sentamu, asked for the use of the word “transition”—is being carefully managed through existing financial planning and assurance arrangements, including consideration of transition expenditure and the savings that are expected from reducing duplication by bringing together NHS England and the department. Our priority, and that of noble Lords, is to ensure that resources are used effectively and, wherever possible, directed towards front-line services and improvement for patients, because that is at the core of this.

While I absolutely agree with the principle of transparency, this very detailed amendment would place in legislation additional requirements for an independently reviewed financial plan. It is at this point that I part company with the amendment. That provision would add an unnecessary process and constrain the Government’s ability to manage the transition flexibly and efficiently. I take the point behind the amendment, and I certainly take the points that noble Lords have raised, but I do not feel that placing these requirements in legislation will get us to where we need to be.

The noble Earl, Lord Howe, the noble Lords, Lord Lansley and Lord Scriven, and the noble Baronesses, Lady Manzoor, Lady Harding and Lady Watkins, raised costs and savings, and other noble Lords also referred to them. The noble Earl, Lord Howe, asked me to write with information; in view of the range of things that were raised, that would be very helpful. I can make some general points: we remain on track to deliver over £1 billion of savings per annum by the end of this Parliament. The whole point of a transition is that it is a process, so I want to make the point that the total saving will be determined by a number of things—including, for example, the number and seniority of staff who leave through exit schemes that are currently under way. I know that noble Lords understand that this transition is a moving process. That does not mean it is wrong to ask for information, but we must take account of the fact that this is something in development and movement.

The noble Lord, Lord Lansley, referred to the National Audit Office and extended a suggestion about volunteering. I understand why the noble Lord said that, but I observe that the National Audit Office is independent, rightly, and it is for it to determine its programme of work.

On the 50% reduction being a final figure, I say to the noble Lord, Lord Stevens—linking with comments I have just made—that, yes, our aim is to reduce staff numbers significantly across the department and NHS England. But, as I said, it cannot be a final figure because we have not gone through the process of identification, et cetera. I heard what the noble Lord read out, and in some ways that is true: it is an ambition and one has to set that. But I do not think anybody would be able to give the final figure with absolute precision. But we are working closely with trade unions and staff across the two organisations and will continue to consult them.

My noble friend Lord Hunt and other noble Lords raised questions about the role of the Secretary of State. As my noble friend indicated, we will return to that in rather more detail—I look forward to doing so—when we look at the power of direction in Clause 11.

On the points raised by the noble Lord, Lord Kakkar, on operational management, transferring NHS England’s functions will not require changes to established clinical audit programmes, NICE-supported diabetes technologies or specialist diabetes services. Those programmes operate through existing statutory and operational arrangements.

The noble Lord, Lord Stevens, asked whether it is still our intention to abolish NHS England by 1 April. Yes, that is our intention, and we recognise that that is a demanding timetable. Of course, as your Lordships will be very aware, it is subject to the parliamentary passage of this Bill.

I am glad that a number of noble Lords raised staffing, including the noble Lord, Lord Stevens, the noble Baronesses, Lady Watkins, Lady Manzoor and Lady Campbell, and my noble friends Lady Royall and Lady Thornton. Change within any organisation is an anxious time for all those who are potentially affected. The changes being proposed here are absolutely no reflection on the quality of the work carried out day in, day out by talented staff, and I am grateful to them. This is about getting the system working for patients and for the public, so we will ensure that people are treated properly and we will continue to communicate information about reforms to staff through the various internal channels, as we have done. I just mentioned our work on consulting recognised trade unions, and we are very grateful for their partnership because it is critical to how we approach this change—I say that as a former trade union official used to this level and kind of reorganisation.

There were questions about retaining the talent of staff, which is key. We have taken a number of measures to retain and to develop talent, including initiating a joint interim recruitment process between NHS England and the DHSC. It includes a focus on temporary lateral moves and internal promotion to retain skills. We are, through organisational development and design work, identifying the key skills and capabilities that we will need in the future. I anticipate that this will support a drive for a more expert department, because we will be focusing very much on the skills we need and on functions to ensure that we can develop and retain expertise.

The noble Baroness, Lady Campbell, used the example of personal health budgets. I am certainly aware, not least because of the campaigning work and experience of the noble Baroness herself in this area, that personalised care has a liberating effect on individuals. I very much look forward to specifically debating those issues when we come to Amendment 178, from the noble Lord, Lord Lansley.

My noble friend Lady Thornton asked about the TUPE regulations and arrangements. Like many noble Lords, I have received a considerable amount of correspondence on this matter. I want to put on record, and I am glad for the opportunity to do so, that the Bill does not remove TUPE protections from anyone. The circumstances where TUPE applies are, of course, set out in the existing Transfer of Undertakings (Protection of Employment) Regulations 2006.

My noble friends Lady Rafferty and Lord Hunt referred to the abolition of governors. I look forward to discussing that issue later in the Bill’s passage, at Clause 30.

In response to the noble Lord, Lord Scriven, I am aware that I am making a general response, and I will look closely at the specific questions that he has asked. I can say that the kind of duplication that we are speaking about includes HR, IT and communications. I have my own experience of this issue, as I am sure other noble Lords who have occupied my position before me will have. Actually, my noble friend Lord Hunt put it well, when talking about the tension—I will call it that —between what Ministers are expected to have control of but have no control of. That creates not just difficulty of duplication but immense frustration, which I also experience from noble Lords in this Chamber—and I understand that.

In those functions that I have just referred to as examples, many of them sat in the department prior to the establishment of NHS England. I do not think this is just a recreation of the pre-2013 system. A number of noble Lords made the point, which I completely understand, about their despair at reorganisations.

The noble Lord, Lord Lansley, also made the point that it was not in this Government’s manifesto. That is true. I recall that, when we came into government, on this very issue we did not want to, as the then Secretary of State made quite clear, enter into reorganisation. But the harsh reality was, as we worked through it and got into our stride, that we realised that it was unsustainable. When faced with what is unsustainable, we can either put effort, resource and energy—otherwise known as blood, sweat and tears—into trying to make something work that we know cannot work or can we bite the bullet. That is what we are doing here.

We are recasting the role of the centre, with respect to the rest of the system. We are making it smaller and changing the way it works, so that the centre does only what it must do, or can do, most efficiently, and so we can better serve patients through local decision-making. Again, we will return to that point, and the relationship between the two, later in the Bill.

17:45

I am most grateful to noble Lords who have engaged with me, through round tables and directly, and who have received the correspondence that I sent. I will be glad to continue to do that as we go through Committee and beyond. I reassure noble Lords that we remain committed to parliamentary scrutiny throughout the transition, and we will continue to publish updates as we move forward.

[Lord Scriven (LD)]

I asked one specific question, which the Minister may not be able to answer at this moment, but perhaps she could put it in writing. As the Minister has just pointed out to the noble Lord, Lord Stevens, is it the Government’s intention to transfer all the staff into the department or is a stand-alone body being looked at as a potential route for those staff?

[Baroness Merron (Lab)]

The intention is the former, but I will gladly write further to the noble Lord on this point.

[Earl Howe (Con)]

My Lords, I am grateful to the Minister for her wide-ranging response, and to all noble Lords who have contributed to this important debate, which has been very useful.

The Committee has spoken with one voice in underlining the scale and complexity of the task which lies ahead and the importance of ensuring that the abolition of NHS England, or its transformation, as the noble and right reverend Lord, Lord Sentamu, put it, is managed carefully, transparently and with proper accountability.

As I said at the outset, we are not opposed to efforts to reduce bureaucracy or to improve efficiency in the health service. However, we have to be confident that the Government have a clear understanding of the costs involved, the savings which can realistically be achieved and the risks associated with a reorganisation on this scale. Above all, we must not lose sight of the people whom these reforms are intended to serve. The ultimate measure of success must be whether patients receive better, safer and more timely care, rather than simply whether we have succeeded in changing the administrative structure of the NHS.

Despite what she said, I hope the Minister recognises that my amendment was put together as a giant probe of the Government’s transition plans, rather than as a model form of words to be written into the Bill. I therefore welcome her assurance that she will reflect carefully on the concerns that have been raised today, particularly around the need for a clear and independently assessed transition plan. We will consider the Minister’s response ahead of Report. However, for now, I beg leave to withdraw my amendment.

Amendment 4 withdrawn.

Amendment 5

Moved by

[Earl Howe]

5: After Clause 3, insert the following new Clause—
“Supply Chain Coordination Limited(1) Before making a transfer scheme under section 2 which relates to shares held by NHS England in Supply Chain Coordination Limited, the Secretary of State must publish and lay before Parliament a report on the proposed future ownership and governance of that company.(2) The report must set out—(a) the person to whom the shares are to be transferred;(b) the reasons for selecting that person;(c) the date on which the transfer is intended to take effect;(d) the person who will exercise the shareholder function during the transfer period;(e) the person who will exercise the shareholder function following completion of the transfer;(f) the arrangements by which the exercise of the shareholder function will be overseen and held to account;(g) any proposed change to the company’s articles of association, governance arrangements, objectives or operating model;(h) the arrangements for ensuring continuity in the procurement, storage, distribution and supply of medicines, medical devices, equipment and other goods required by the health service;(i) an assessment of the principal risks to procurement and supply resilience arising from the transfer;(j) arrangements for managing shortages, disruption or failure of supply;(k) the arrangements for retaining staff with expertise necessary for the continued operation of the company;(l) the contingency arrangements which will apply if the transfer cannot be completed or gives rise to a material risk of disruption;(m) a summary of any independent assurance obtained concerning the proposed transfer and the continuity and resilience of the services provided by the company. (3) The Secretary of State must consult such persons as the Secretary of State considers appropriate before preparing the report.”Member's explanatory statement
This new clause would require the Secretary of State to report to Parliament on the proposed ownership and governance of Supply Chain Coordination Limited before transferring the shares held in that company by NHS England.

[Earl Howe (Con)]

My Lords, Amendment 5 stands in my name and that of my noble friend Lord Kamall. I am grateful to the noble Lord, Lord Hunt of Kings Heath, for his Amendment 211 in this group.

Amendment 5 concerns the future ownership and governance of Supply Chain Co-ordination Limited following the abolition of NHS England. It is a rather more specific amendment than the one we have just debated, but it raises an important question about the wider process of transition, in particular how the Government intend to ensure that essential services and functions continue to operate effectively as NHS England is abolished.

As I emphasised earlier, NHS England sits at the centre of an extraordinarily complex and interconnected healthcare system, with responsibilities, contracts, assets and operational relationships extending throughout the NHS. When we interfere with one part of that system, we need to be certain that we understand what depends upon it. This is particularly important in relation to procurement and supply chains.

NHS England currently holds the shares in Supply Chain Coordination Limited, which plays a central role in the NHS Supply Chain arrangements through which hospitals and other healthcare providers obtain essential equipment, medical devices and supplies. These are functions which may not attract a great deal of public attention, but they are absolutely fundamental to the day-to-day operation of the health service. Hospitals depend on reliable access to medical equipment, consumables and other essential supplies in order to deliver treatment. When those supplies are disrupted, the consequences can obviously be very serious indeed. Procedures can be delayed, costs can increase and clinical staff can find themselves unable to provide the care that their patients need. It is therefore essential that, as the Government undertake this reorganisation, we do not inadvertently destabilise or create disruption in areas of the health service which are currently operating effectively.

That is the concern which this amendment seeks to address. As NHS England is abolished, its shareholding in Supply Chain Coordination Limited will need to be transferred. Our amendment does not seek to prevent that transfer, nor does it prescribe what the future ownership arrangements should look like. Instead, it asks the Government to set out clearly how that transfer will be managed, who will be responsible for the company afterwards and what measures will be taken to ensure that its operations continue without interruption.

There are some fairly straightforward questions here. First, who will assume ownership of the company and who will exercise the shareholder responsibilities, both during and after the transition? It surely cannot be intended that day-to-day control of the organisation will fall to the Secretary of State. But if not, then to whom and under what organisational structure? Secondly, pursuant to that, what governance and accountability arrangements will be put in place? Will there be any changes to the company’s operating model, and, if so, what assessment has been made of their potential consequences? Thirdly, and perhaps most importantly, what assurances can the Government give that the transfer will not disrupt the procurement, storage or distribution of essential supplies across the health service? I would be particularly interested to hear what assessment has been made of the risks involved in transferring these responsibilities and what contingency arrangements will be available if the process proves more complicated than anticipated.

Procurement and supply chain management depend on experienced people, established relationships and systems which have been developed over many years. We know that NHS reorganisation will involve staff cuts. To what extent will this organisation be subject to cuts in staff, and at what levels? What steps are being taken to ensure that the relevant expertise is retained and has any independent assurance been obtained about the resilience of these arrangements during the transition?

More broadly, I regard this amendment as representing a microcosm of the larger questions that surround the abolition of NHS England. The success of this reorganisation will depend not only on whether the Government can transfer functions and responsibilities on paper but on whether the systems that patients and clinicians rely upon continue to work in practice. I hope the Minister will be able to provide some reassurance on these points. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I very much agree with the noble Earl, Lord Howe, that procurement is important in itself, but that it is an illustration, in a sense, of how the new arrangements might play out. Where I disagree with him is that he was really implying NHS Supply Chain is doing a good job, and we do not want to disrupt it. Actually, there are a lot of concerns about the current performance of the supply chain, which I would like to come to, because this is an opportunity to improve what it does, and, in particular, to try and get the relationship between NHS Supply Chain and local NHS bodies on a much better footing.

My Amendment 211 is grouped with Amendment 5 and has the support of the noble Lord, Lord Markham, the former Health Minister, who has been a great advocate of value-based purchasing. I declare an interest as patron of the Health Care Supply Association, the organisation for professionals in health service procurement, who contribute so much to a very important function.

Procurement is there to ensure value for money for the health service, but it can do much more. We know since Covid of the essential need for supply chain resilience. Effective procurement can provide this, ensure investment in innovation and support UK industry. I believe it can link closely with the Government’s ambitions on matters of sovereignty, regional development and growth. NHS Supply Chain has a clear role in this, and it is absolutely right to scrutinise what the arrangements are going to be when the shares transfer from NHS England to the Department of Health.

In particular, I want to raise the shortcomings of NHS Supply Chain. The 2024 Public Accounts Committee report found that NHS England had been weak in its oversight and support of NHS Supply Chain. The PAC reported that neither NHS England nor the department had validated the savings the company reported, and that trusts’ satisfaction with the service was already “in steady decline”. Nor was the committee’s criticism confined to NHS England. It found that the department, which owned the company before 2021, had been “far too lenient” in its oversight.

Returning the shareholding to the department really does not change this one way or the other, but, as I said earlier, it is a chance to put the relationship between NHS Supply Chain, its shareholder, Ministers and the NHS organisation it serves on a much clearer footing. I want to make the point that it is there to serve the NHS. It does not, however, behave in a way that actually recognises that its customers are local NHS bodies. I should say here that there is a view that it is very arrogant in its dealings with NHS bodies. This is what we want to see changed, and I hope ministerial control will actually do something about it.

The ABHI has also reported to me that currently, NHS Supply Chain does not publish the agendas, papers and minutes of its board meetings. I find that very surprising. The noble Lord, Lord Scriven, will raise this in relation to Clause 11, but at the very least I hope to get some assurance that this will be put right.

I also ask the Minister whether, under the department, NHS Supply Chain will continue with its commitment to value-based purchasing. This is very important. I have long argued for it, and the noble Lord, Lord Lansley, is very much with me on this. The point is getting away from always going for the lowest price, and going for quality to improve patient outcomes. I acknowledge we are making progress, and the department itself is very supportive.

I want to quote one example. Value-based purchasing was launched this year to ensure a higher quality of healthcare by raising the standard of procurement. During a pilot in the South Tyneside and Sunderland NHS Foundation Trust, working with Essity, patients were provided with the most appropriate absorbent continence product for their clinical needs and preferences, even if that product was more expensive than other options under consideration. The results showed an 8% reduction in the number of continence products used and a 48% reduction in leaks, and 71% of patients said they would now find it easy to change the product themselves. This is a wonderful example of hugely improved patient outcomes because they did not go for the cheapest products—so this is what this is all based on.

18:00

We know that NHS Supply Chain has committed to this, but there is a tension. It has something called the core list, which enables it to manage the sourcing and supply of a core range of standard commodities on behalf of all providers—the key phrase here is “standard commodities”. When it is a question of scissors, clinical waste bags, batteries and pencil sharpeners, this is eminently sensible. However, a few days ago, NHS Supply Chain slipped on to its website—with no advance warning and no announcement to key trade associations such as the Urology Trade Association—a list of an additional 79 categories of product to be assessed for potential inclusion in future versions of the core list. This included urinary catheters and colostomy bags. These are not “standard commodities”; these are very personal things. I am worried that NHS Supply Chain, by doing this without any consultation at all, will reduce patient outcomes.

Clearly, this is a little aside from the core aim of this legislation, but the way this is handled will be an indication of how future arrangements are going to be. NHS Supply Chain should, first, commit to pursuing value-based purchasing, and, secondly, recognise that, although it is owned by the Secretary of State, or will be, its job is to help the local NHS and so it should not treat it in an arrogant way but, basically, as its customers.

[Baroness Finlay of Llandaff (CB)]

My Lords, I added my name to the amendment tabled by the noble Lord, Lord Hunt of Kings Heath, because this goes almost to the heart of the way that we account for what we do and what we buy in the NHS.

One of the problems is the accounting lines. A piece of equipment that might appear, at face value, to look expensive in fact saves enormous expenditure and lessens patient distress and morbidity, from a different budgetary line. The saving is a fallacy. I would welcome value-based procurement. I acknowledge the work that is being done by the medical technology and innovation directorate in the department and encourage that this goes across the whole of the NHS and social care system.

It is the clinicians who know that the cheapest is not necessarily the best, but, at face value, that may not always seem adequate. NICE has produced examples of where the cheapest is certainly not the best. Let me give one specific example, relating to something that is quite expensive: namely, cardiac pacemakers. Most cardiac pacemakers have wires. There are some which are eight times more expensive, but they do not have leads on them. That might seem a lot of extra money but, if patients have had radiotherapy to their shoulder and the left side of the chest, or if they are at very high risk of infection because they are on immunosuppressives or because they have a condition where they are immunosuppressed, then actually they are at high risk of getting infection on the leads because the leads are a foreign body in their body. The cost of managing sepsis, with patients in ICUs, vastly outweighs the cost of using different pacemakers for a small number of patients.

Think about urinary catheters. Patients who self-catharise may find that one type is much easier for them to use than another, and if they use it well and properly then their risk of infection is much lower. Generally, self-catheterisation is easier for men than it is for women, but certainly women who have a disability may find that they have got used to manipulating one type of catheter to self-catheterise. It becomes very cost-effective.

The clinicians are the ones who know what the outcomes are for particular devices, so that needs to be embedded in the tendering process. I hope that the voice of the clinicians determining the overall outcomes will be considered ever more as this goes forward. In Wales, we have the Value-Based Health and Care Academy, at Swansea University, which produces interesting work and is internationally recognised as a leader in the field because of its different way of thinking. I hope that there will be reporting to us on how this works when the change has happened.

[Lord Lansley (Con)]

My Lords, I want to speak briefly in support of Amendment 211, in the names of the noble Lord, Lord Hunt of Kings Heath, and the noble Baroness, Lady Finlay.

I declare an interest in that I am an officer of the All-Party Parliamentary Group on Access to Medicines and Medical Devices, which has held meetings on the value-based procurement of medical devices. I chair a group looking at breakthrough implantable devices, which has taken an interest in the procurement of just the kinds of devices that the noble Baroness, Lady Finlay, was talking about and in the importance of clinical input to understanding the potential value of such innovative devices.

Some Members of the Committee will know that I have been an advocate of value-based procurement and, where medicine is concerned, value-based pricing as an approach in the National Health Service. There is some good work being done in the department on promoting value-based procurement; we just need to make sure that it is understood and implemented correctly. I have been worried by evidence from some early tenders that the attitude is that the assessment of value should be conditional upon the achievement of a pricing threshold. Sometimes the pricing threshold is set at a point where the calculation of potential value is effectively nullified. If we are serious about understanding value-based pricing, we cannot put in a pricing threshold. You may well attach greater or lesser weight to the pricing element, but you cannot attach a threshold and believe that you are implementing value-based pricing. Quite often, part of the value assessment is to look at issues of patient experience, the outcomes that are to be achieved, the long-term life of a product and how it is used, to arrive at the overall value of a product. This is perfectly normal in commercial procurement. I do not think we are talking about something that should be regarded as exceptional to the NHS. It should be something that is regarded as normal and best practice in procurement.

It is slightly dispiriting in a sense, as I have seen an awful lot of progress on procurement in the NHS. Some 30 years ago, I was working with Unipart—before I came into Parliament—in trying to encourage the NHS, for example, to have just-in-time delivery and barcode-based procurement. That was an awfully long time ago and we have progressed a long way. It seems to me that, if we are keeping pace with the best procurement practices —and I hope the NHS will do that—we should be looking at a value-based system. I very much support what the noble Lord, Lord Hunt, said about that.

[Lord Scriven (LD)]

My Lords, I speak for these Benches on this short but important group. I thank the noble Earl, Lord Howe, for the amendment on Supply Chain Coordination Ltd and the noble Lord, Lord Hunt of Kings Heath, for his important amendment on value-based procurement.

These amendments may look technical, but they go to something that matters in every clinic and every operating theatre: how the NHS buys what it needs and who is accountable when things go wrong. NHS Supply Chain manages an estimated £8 billion a year of NHS spending on products, and, since 2022, it has carried out the department’s PPE programme. Yet under Clause 2, its shares can be moved by a transfer scheme at the Secretary of State’s discretion. There is no requirement to tell Parliament where they are going, who will exercise the shareholder role, or how continuity of supply will be protected.

Asking for a plan first seems modest. If the pandemic taught us anything, as the noble Lord, Lord Hunt, suggested, it is that supply chain resilience is first and foremost a patient safety issue.

However, a report is not a safeguard in itself. The real risk is that the transfer happens in the middle of a reorganisation, cutting the central headcount by half. The very people who understand how the company works may be gone before the scheme is made. The National Audit Office found that Supply Chain Coordination Ltd was meeting only seven of its 18 key performance indicators and that trusts spend more than £3 billion outside it. A company with that record needs careful handling, not a transfer done in a rush.

On value-based procurement, we welcome the direction of travel. As the noble Lord, Lord Lansley, just pointed out, this is not novel. We do not even have to take his experience of Unipart as an example. We can look at value-based procurement elsewhere: in Denmark, Canada, Italy and even Indonesia. There are models which the Government could use to look at how it is done.

The national guidance published in June is a genuine step forward, asking what delivers the best outcome across the whole patient pathway, rather than simply what the cheapest price is. But with NHS financial pressures, the temptation will always be to grab the lowest price today, without the skills, the capacity, and a finance regime that rewards long-term value. So I ask the Minister: what thinking is being done, not just for the pilots but as part of the new powers that the Secretary of State will have from the transfer of NHS England, on rewarding long-term value in the financial regime? What changes, if any, will the Government make to the financial regime?

There is a wider point that both amendments expose. NHS procurement still sits apart from the rest of the public sector. When the Procurement Bill passed through this House, my noble friend Lady Brinton, with support from all sides, including from the noble Lord, Lord Hunt, asked why the NHS should be treated differently. She warned that the NHS arrangements were not visible and that they were

“SIs at the discretion of any Secretary of State for Health”.—[Official Report, 28/11/22; col. 1578.]

Today, we have one regime for healthcare services and another for goods. NHS buyers are told to take legal advice on how the new value guidance fits both. With NHS England abolished, all that discretion will sit with the Secretary of State, and my noble friend’s warning has become even more relevant.

Therefore, I ask the Minister four simple questions. First, where will the shares in Supply Chain Coordination Ltd go, and when, and will Parliament see the plan before the transfer is made? Secondly, what independent assurance has been commissioned on the continuity of supply during the transition? Thirdly, after NHS England’s abolition, who will own value-based procurement and make sure that it is built into national service frameworks? Fourthly and finally, will the Government now review whether two separate procurement regimes for NHS services and goods still make sense, or will they at least publish how the boundaries between them will be policed, once the Secretary of State holds the pen on both? These are modest amendments, asking for sensible things, and I hope the Minister can give the Committee reassurance.

[Baroness Merron (Lab)]

My Lords, I most grateful to noble Lords for their observations and the way they have dealt with this. At the outset, I pick up the point that my noble friend Lord Hunt started with and others, including the noble Baroness, Lady Finlay, developed further. We are particularly concerned with personal products and products that need to be personalised. The illustrations that noble Lords have given have been most helpful. The reason for the changes is to see more of that.

18:15

I will address Amendments 5 and 211 together. Amendment 5 in the name of the noble Lord, Lord Kamall—I thank the noble Earl, Lord Howe, for moving it—highlights the importance of a clear and managed transition as we move towards the abolition of NHS England. In answer to one of the key points that the noble Earl, Lord Howe, raised, the intention is for the shareholding in Supply Chain Coordination Ltd —I am being very formal—which we refer to as NHS Supply Chain, to transfer to the department as part of the wider transition. The transfer of shares will have no impact on the services delivered by the company. NHS Supply Chain will continue, as it always has, to play its role in securing value for money and ensuring resilient supplies for the NHS.

To pick up some of the questions that were raised, I mentioned ensuring that there will be no disruption to storage and supply; the noble Earl, Lord Howe, raised this in particular. The transfer does not in itself alter operational responsibilities or contractual arrangements, and NHS Supply Chain will continue to provide services through the transitions. Our anticipation is that the current arrangements will remain broadly in place. As part of the new operating model, consideration will be given more widely to the efficient and effective management of shareholdings.

I heard my noble friend Lord Hunt express concerns about the way NHS Supply Chain currently operates. Consideration will be given to how management of the operation can be more efficient and effective. As I said at the outset, I heard very clearly the reasons for that, so I need no persuading.

My noble friend also asked about the commitment to value-based purchasing, which other noble Lords, including the noble Lord, Lord Lansley, have spoken positively about. NHS Supply Chain is fully committed to the adoption of value-based procurement and has moved to a “comply or explain” model for future frameworks. NHS Supply Chain also considers the application of pricing threshold approaches on a case-by-case basis, looking at specific market dynamics.

To answer the noble Lord, Lord Scriven, I will refer to Supply Chain Coordination Ltd’s strategy. The strategy focuses on the principles of—and I am lifting these words, so I ask noble Lords to bear with me—

“buying smart, supplying right, and partnering expertly”.

I am sure the noble Lord is familiar with that kind of terminology. I would translate that to prioritising the needs of patients, communities and outcomes in how we source and supply. That is key.

With regard to some of the questions that the noble Lord, Lord Scriven, raised about shares and the plan, NHS Supply Chain will continue, and it is going back to the department, which is where it was before. I will look at the other very specific points in considering this whole area.

To return to Amendment 5, it would introduce a new statutory requirement to publish and lay before Parliament a formal report before NHS England shares in the NHS Supply Chain could be transferred. As I have said, the department previously exercised that shareholder function, and the intention is to return to those arrangements. For that reason, we consider the amendment to be unnecessary.

On Amendment 211, I welcome that my noble friend Lord Hunt, the noble Lord, Lord Lansley, and other noble Lords have been long-time advocates of value-based procurement. I am grateful to your Lordships’ House for the ongoing support for this policy. In June, we delivered on the commitments made in the 10-year health plan and the life sciences sector plan to publish national guidance for value-based procurement for medical technology. I welcome that guidance having shifted the focus of procurement decisions towards value and—I emphasise—outcomes for patients, as well as towards the health system and the environment, rather than just towards the lowest cost. Publishing the guidance is just the first step. The department has set out its implementation plans, including commissioning independent monitoring and evaluation of the guidance, with annual reports over the next three years—which of course will be published—on the impact of the guidance. It is the intention that business as usual means value-based procurement when it comes to NHS procurement teams purchasing medical devices, consumables and services. Our existing reporting arrangements will help to ensure that this is the case.

[Earl Howe (Con)]

My Lords, I am grateful to the Minister for her response and to all noble Lords who have contributed to this debate. I am particularly grateful to the noble Lord, Lord Hunt of Kings Heath, for his insights into the performance of the NHS Supply Chain and its current shortcomings. I was also very impressed by his advocacy in favour of value-based procurement—which, incidentally, I would distinguish from value-based pricing, a policy in relation to which, as a former Health Minister, I bear the scars. I very much agree with the noble Lord, Lord Scriven, that we need reassurance that responsibility for value-based procurement will rest with NHS Supply Chain with active ministerial support. We heard the necessary reassurance on that from the Minister.

I admit that the criticisms of NHS Supply Chain voiced by the noble Lord, Lord Hunt, are ones that I chose to gloss over, because, as I said at the outset, my concern was simply to ensure that the abolition of NHS England does not disrupt the essential services and systems on which the wider health service depends. NHS Supply Chain is an important example of this, and we must be confident that its future ownership and governance arrangements are properly considered and that continuity of supply is protected throughout the transition. I was largely reassured by what the Minister had to say about this but will study her reply carefully. Ultimately, changes to the administration of the NHS must not come at the expense of its ability to deliver care to patients.

I hope that the Government in turn will reflect on the points raised today, but for now I beg leave to withdraw my amendment.

Amendment 5 withdrawn.

Clause 4: Reducing inequalities

Amendment 6

Moved by

[Baroness Jones of Moulsecoomb]

6: Clause 4, page 3, leave out lines 22 to 29 and insert—
“1C Duty to improve public health and reduce health inequalities(1) The Secretary of State must, in exercising functions in relation to the health service—(a) take all reasonable steps to improve the health of the people of England and prevent illness,(b) reduce health inequalities between the people of England,(c) take all reasonable steps to reduce inequalities in the ability to access health services and in the outcomes achieved through the provision of health services, and(d) address the social, economic and environmental determinants of health, including in relation to housing, education, employment, income and environmental conditions.(2) In discharging the duties under subsection (1), the Secretary of State must take account of the need to prevent ill health by addressing its causes, as well as by providing services for the treatment of illness.”Member's explanatory statement
This amendment strengthens the Secretary of State’s duties to improve public health and reduce health inequalities, including by addressing the social, economic and environmental determinants of health and preventing illness rather than relying on treatment alone.

[Baroness Jones of Moulsecoomb (GP)]

My Lords, I will speak to the four amendments in this group that are in the name of my noble friend Lady Bennett of Manor Castle. I shall speak also on behalf of the noble Baroness, Lady Whitaker, who is ill and unable to be here. She asked me particularly to mention that she supports Amendments 15, 16 and 17 in this group, on inequalities.

On Amendment 6, a duty of “must have regard to”, as is currently in Clause 4, is not much of a duty. We can have regard to many things, but it does not mean that we will do anything about them. I support the amendments in this group that want to strengthen that duty to something where we can see some action. The aim of this amendment is to strengthen it further and to put improving public health, reducing inequalities and addressing the social, economic and environmental determinants of health into the Secretary of State’s statutory responsibilities.

We talk a great deal about the pressure on the NHS. We talk about waiting lists, hospital capacity, workforce shortages and the money needed keep services going. These are all extremely important, but we need to ask some more fundamental questions. Why are so many people becoming ill in the first place, and why are some people so much more likely to become ill than others? As the noble Lord, Lord Crisp, said on an earlier group, we need to shift our focus from treating sickness to creating health. Health is not simply a matter of what happens when somebody walks into a GP’s surgery or a hospital. It is shaped by conditions in which people are born, grow up, work and live. It is shaped by whether somebody has a secure home, a decent income, good food, good education, safe working conditions and clean air to breathe.

These things should make up a health policy. A person living in a cold, damp home, especially near a busy road, as so many people do here in London, is more likely to suffer from respiratory problems. Someone who cannot afford nutritious food faces consequences for their lifelong health. A child growing up in poverty can face disadvantages that will affect their health for the rest of their lives. This amendment takes all that into account and would require the Secretary of State to take reasonable steps to do something about it, because here in the UK, those in the most deprived areas can expect to live almost 20 healthy years fewer than those in the least deprived areas. That is a staggering statistic.

Prevention will not eliminate the need for hospitals, medicines or specialist care, but a health service should not focus just on what happens after people become ill. Prevention means more than telling people to make healthier choices. It means making those choices possible. It means tackling food poverty and ensuring that people can afford nutritious food. It looks like investing in public health and early intervention. There is not much point in treating the consequences of poverty without addressing the circumstances that make people ill.

What is the point of treating respiratory disease while allowing people to live in damp homes or to breathe polluted air? Human health and the health of the natural world are connected. Cleaner air and water, access to nature, healthier food systems and action to protect us from the effects of the climate crisis are all public health measures. As we know, the benefits of a healthy environment are not shared equally. People on lower incomes are often least able to move away from pollution, poor housing and unhealthy surroundings. The inequalities that we see in health are therefore connected to inequalities in wealth, power and the quality of places where people live. The noble Baroness, Lady Nargund, also spoke about inequalities, a primary pressure on our beloved NHS.

The gap in healthy life expectancy between the most and least advantaged communities is a measure of inequality that the Government should actively try to reduce. A statutory duty will not by itself remove these inequalities, but the wording of a Bill does matter. It establishes what the Government are required to do rather than merely saying what they would like to do.

Amendments 15, 16 and 17 aim to strengthen the provisions in Clause 4 for all communities facing health inequalities. These amendments address three essential requirements—visibility in health data, recognition in decision-making and accountability for progress. For example, Gypsy, Roma and Traveller communities experience some of the most severe and persistent health inequalities in England. They face poorer physical and mental health, barriers to accessing healthcare and discrimination within healthcare settings. The 2021 census found that Gypsy or Irish Traveller people were more than twice as likely to report bad health or very bad health as the rest of the population of England and Wales overall—12.5% compared with 5.2%.

Nearly one in six reported being disabled and limited “a lot” in their daily activities by long-term physical or mental health conditions, compared with around one in 13 of the overall population. Research has found that Gypsy or Irish Traveller women in England and Wales are twice as likely to die by suicide as those in the white British women category. Yet a 2020 review by Friends, Families and Travellers found that of 79 local suicide prevention plans covering 113 areas in England, only five mentioned Gypsy and Traveller communities, and only two included action to address suicide inequalities.

18:30

Therefore, despite the inequalities in health outcomes, the communities’ needs are not being consistently identified in national health data or adequately reflected in the planning and delivery of services. Collecting properly disaggregated ethnicity data is essential. Gypsy, Roma, and Traveller communities are not a single homogenous group, and grouping them together under one category can obscure important differences in their health experiences and outcomes. Data should enable us to understand the distinct experiences of Gypsy, Roma, Irish Traveller and other communities, rather than masking inequalities within broad categories.

More broadly, the same challenges affect other inclusion health groups, including people experiencing homelessness, vulnerable migrants, people in contact with the criminal justice system, and victims of modern slavery. These groups often experience overlapping disadvantages, social exclusion and barriers to healthcare. Clause 4 provides an important opportunity to address these inequalities but, as it stands, a general duty to “have regard to” reducing inequalities and access to health services and health outcomes will not, by itself, ensure that the people experiencing the greatest inequalities are identified, considered and supported. These amendments would help make that duty effective in practice.

Amendment 15 would require national health data systems to collect, analyse and publish data sufficient to identify and monitor these inequalities. Amendment 16 would ensure that the particular barriers facing inclusion health groups are considered when the Secretary of State exercises the health inequalities duty. Amendment 17 would require annual reporting on progress, including action taken in relation to Gypsy, Roma, and Traveller communities—this is essential for transparency and accountability. These amendments are all complementary. They would help ensure that inclusion health groups are visible in the evidence used to make decisions. They build on existing commitments to reduce health inequalities, and they aim to ensure that the system we have is better able to recognise and respond to the needs of these communities. I beg to move.

[The Deputy Chairman of Committees (Lord Faulkner of Worcester) (Lab)]

I should advise the Committee that if this amendment were agreed to, I would not be able to call Amendments 7 to 15 for reasons of pre-emption.

[Lord Patel (CB)]

My Lords, we are entering the phase of debate on the Bill which I personally consider to be the most crucial part. Why do I consider it to be the most crucial part? It is because tackling health inequality is central to the revival, if not the survival, of the NHS and the broader economy.

I will speak mainly to my Amendments 7, 13 and 19, but before I do so, I want to say something because I feel strongly about it. I regret that consultants have decided to go on strike. No doctor should ever, under any circumstances, withdraw their services from the sick and the vulnerable. I think any doctor, and I hope every doctor in this House, would support that idea. They might have grievances, but they could settle those without going on strike, and they should not withdraw services. I hope the professional bodies, including the royal colleges, will align with that comment.

Having said that, my amendments about reducing inequalities are there because what we have in the Bill is a direct transfer of the issue of reducing inequalities from what was part of NHS England’s duties and was already in the duties of ICBs. There is nothing new in the Bill about reducing inequalities. It is a great pity that an opportunity is being missed by this Government to put a mark on how to reduce inequality. Why do I say “this Government”? It is because in the last 30 years, it was only once that we succeeded in reducing health inequalities, and that was from 2000 to 2010. An academic review, which was a proper assessment, demonstrated that, in mortality, infant mortality and ill health, the strategy devised by the then Labour Government managed to reduce health inequalities. But we have now come to a point where they are all rising for all kinds of reasons.

Who were the people who were responsible at the time? Their names were Alan Milburn; John Reid, now the noble Lord, Lord Reid; Yvette Cooper, now Secretary of State for Health; the noble Lord, Lord Darzi of Denham, who produced a report on the NHS; and Andy Burnham, the last Secretary of State for Health in that Government, and now the Prime Minister. Surely the present Government can find people of same calibre who can tackle health inequalities—or maybe not.

The strategy was a cross-governmental public service agreement—PSA—which was a legally binding framework used by the Treasury in the spending review process. It was as simple as that. It could be argued that my amendment is too strong. It would make the Secretary of State responsible, and I might be told that cannot be, because it removes the Secretary of State’s autonomy and flexibility, and therefore putting that in the Bill is not appropriate. If it is not, it does not make the policy of inequality strategy development inappropriate. As demonstrated between 2000 and 2010, the then Government found a way—cross-governmental ministerial responsibility—where, although the strategy was based on ill health, all the other Ministers were responsible for making sure that their ministries contributed to that improvement in reducing health inequality.

Therefore, if the Minister does not like my Amendment 19, there might be other ways for the Government to decide how the same could be achieved through another strategy; for instance, the same kind of agreement that Government did in 2000-10 or through Cabinet Secretary responsibility, as the Cabinet Secretary is responsible for making sure that all the Ministers and different government departments contribute and are mindful of a strategy that reduces health inequality.

In my view, if we do not do this, and there is no strategy coming forward, nothing will change. We will be talking about the same things that we have been talking about for the last 15 years, quoting the same statistics that have already been given about life expectancy being reduced in disadvantaged populations, how the time people spend being unhealthy will increase, how infant mortality will go up, how maternal mortality will go up, as it is doing now, and all the other things.

I thank the noble Baroness, Lady Cass, who might speak after me on children’s issues, and the noble Baroness, Lady Manzoor, who added her name to my amendment. I hope the Minister might agree to four things that I will ask her. I am not asking questions but asking her to agree that health equality and health outcomes are key to the overall welfare of the NHS and the broader economy; that now, after two decades, there has not been any improvement; that the improvement that previously occurred was as a result of a cross-government strategy; and that the increase in health inequality is being driven by rising ill health in England, but the Bill does not have a plan for the Secretary of State, a Minister of the Crown or Ministers in other Governments to demonstrate how they will reduce inequalities.

[Baroness Cass (CB)]

My Lords, I will be very brief. I support the amendments from the noble Lords, Lord Patel and Lord Hunt, and the noble Baroness, Lady Tyler. It will not surprise noble Lords to hear that I plan to focus on children yet again, but, as my amendments on inequalities in children come much later in the Bill, I will defer to other noble Lords to speak on this group. However, I will give noble Lords a spoiler alert: the Royal College of Paediatrics and Child Health’s State of Child Health report shows that inequalities are widening, particularly in marginalised groups, such as those living in deprived circumstances, or minority ethnic groups. There will be more of that anon; meanwhile, I defer to my colleagues.

[Baroness Tyler of Enfield (LD)]

My Lords, it is a great pleasure to follow the noble Baroness. As the noble Lord, Lord Patel, has already made very clear, this is a very important group of amendments: it gets to the nub of what we should be talking about for the NHS. If I am honest, quite a few of these amendments are calling for quite similar or interconnected things and outcomes. I do not mind too much how we get there, as long as we do.

I want to speak specifically to Amendment 18 in my name; I thank the noble Baronesses, Lady Royall, Lady Cass and Lady Lister, for adding their names. I will also briefly touch on Amendments 8 to 10, in the name of my noble friend Lady Walmsley, who, sadly, is unable to be in her place today, and to which my name is added. I will also speak—briefly, I hope—to Amendment 14 in the name of the noble Lord, Lord Patel of Bradford, who is also unable to be in his place; again, my name is attached. There are also other very important amendments in this group to which I am very sympathetic, in particular Amendment 20 in the name of my noble friend Lady Pidgeon.

The case is well known and has been well made already, so I will very briefly say why tackling health inequalities more effectively is so important. All the research shows that the nation’s health is under real strain. Analysis of healthy life expectancy internationally shows, sadly, that we are falling behind. We now have an 18-year gap in life expectancy between different postcodes in the UK. Of course, it is not just about health, important as that is to individuals, but about economics—what I like to call well-being economics. A nation cannot prosper while large parts of its population are having their lives cut short and while its most deprived communities are, on average, living only 52 years in good health. The number of people with a work-limiting health condition is rising, and poor health among young people is one of the drivers of the increasing number of 16 to 24 year-olds who are NEET—not in education, employment or training.

Before we get too despondent, if you flip it on its head, the good news is there is real potential for what I would call health-enabled growth. Modelling by the Health Foundation suggests that returning just to 2014 levels of health would see 600,000 people back in work, grow GDP by 2% and save the Treasury £70 billion nationally.

I think we all understand that health inequalities are driven not simply by how the NHS functions and operates but by wider social, economic and environmental factors, including poverty, poor-quality housing, lack of green space, poor working conditions and barriers to accessing affordable and nutritious food. I know that, if she were here, my noble friend Lady Walmsley would really want to emphasise that.

As others have already pointed out—the noble Lord, Lord Patel, made this point very strongly—there is a real opportunity to place in the Bill a stronger duty on the Secretary of State to improve health and reduce health inequalities, but that needs to be supported by a statutory framework for co-ordinated cross-government action and accountability. It is an overall package we need, if you like. Coupled with consistent joint working at national and local level, this could really support the shift that I think we all want to see from sickness to prevention. It is in the 10-year plan and the devolution agenda.

18:45

I turn to Amendments 8 to 10 in the name of my noble friend Lady Walmsley. Clause 4 currently transfers only existing duties on NHS England to the Secretary of State regarding equity in access and outcomes from healthcare services. The clause does not strengthen these duties in any way or address the wider determinants of health across government, as we have been discussing. This really is a missed opportunity and is why my noble friend’s Amendment 8 is so important. It would strengthen the Secretary of State’s duty on reducing health inequalities from a duty to “have regard” to the need to reduce them to a duty to “take steps to achieve” their reduction. Actually taking action will make the difference. My noble friend’s Amendments 9 and 10 are simply consequential on that, so I will not go into any detail there, but my final point on Amendment 8 is that a stronger health inequalities duty would send a signal to the Secretary of State and all Ministers that Parliament expects them to actively take steps to prioritise prevention alongside treatment, rather than just having regard to it.

My Amendment 18 is about requiring the Secretary of State to produce a health inequalities strategy and an annual report to Parliament on it. It is similar to Amendment 19 by the noble Lord, Lord Patel, but I have been a bit more generous: he gave six months and I suggest a year. The need for such a strategy was very well debated in the other place recently during the passage of the Bill, and by the Health and Social Care Select Committee. Both found that just changing a duty, although important and necessary, is not sufficient for achieving the goals that I think we all want to see. What is needed is action across government, nationally and locally. It took me back to my days, a very long time ago now, when I was director of the Social Exclusion Unit in government: I remember seeing how central co-ordination can support cross-government working on what you might call those wicked cross-cutting issues, such as homelessness, health inequality and other things, and really start to make a difference.

There was a time when strategies were slightly out of fashion, but maybe times change: we have seen a recent strategy on women’s health and child poverty, and I know and am very pleased that the Minister is herself developing a mental health strategy, which I very much look forward to. Perhaps the time has come for a cross-government health inequalities strategy with the proper parliamentary accountability built in.

I will finish by talking briefly about Amendment 14. I was pleased to put my name to this amendment in the name of the noble Lord, Lord Patel of Bradford; the noble Lord, Lord Hunt, has also added his name. I know that, if the noble Lord, Lord Patel, had been here, he would have very cogently set out the absolutely compelling case for recognising coastal health inequalities. I want to acknowledge his outstanding work.

I want to focus briefly on the consequences for prevention, mental health and young people. The difficulties facing coastal communities are not confined to the prevalence of illness. They reflect a combination of poorer health, economic disadvantage, restricted access to services, limited transport and, in many places, fewer opportunities for young people, and these factors compound one another. Poor access to prevention and early intervention can allow ill health to become more serious, and long-term illness can then push people out of employment. Economic inactivity and financial insecurity can worsen health and well-being, and it is a vicious cycle.

Mental health needs to be front and centre of any response. Many coastal communities face particular challenges in accessing timely mental health support, particularly for children and young people. In places where transport is difficult and specialist services can be many miles away, access to early intervention can become a serious problem. It is acute when it comes to suicide prevention. The relationship between mental health, isolation, economic insecurity and access to services is so important in these communities when support is difficult to reach. I am sure that if the noble Lord, Lord Patel of Bradford, had been here, he would have put it far better than I can, but his amendment would ensure that, in exercising health service functions, the Secretary of State has specific regard to reducing inequalities between coastal and inland communities, particularly in prevention, planning and commissioning and the health workforce.

[Lord Hunt of Kings Heath (Lab)]

My Lords, the noble Baroness, Lady Tyler, and the noble Lord, Lord Patel, made some important points about cross-government working. I was thinking back to what the noble Lord, Lord Patel, said, basically that what started under Tony Blair was continued under Gordon Brown. It was backed up by, first, a specific Cabinet committee, which underpinned the inequalities work, and, secondly, by what were called PSA targets, which tied different departments in. I think that was a good mechanism. In defence of the Government, though, the important work that is being undertaken in relation to health inequality by Alan Milburn, working with different government departments, is going to be pivotal because it embraces the terrible outcomes for so many people who come under the NEET category. It is also looking at the dreadful mental health support for children and adolescents, which goes to the heart of many of these issues. If we can pull this off, we can start to achieve some of the equality issues that we have been talking about.

Like the noble Baroness, Lady Tyler, I am here to say a few words about coastal health because the noble Lord, Lord Patel of Bradford, told us we must. Five years ago, the Chief Medical Officer devoted his 2021 annual report to health in coastal communities. He identified high levels of poor physical and mental health, an ageing population with increasingly complex needs and serious challenges in recruiting and retaining the healthcare workforce. The noble Lord, Lord Patel, basically has three asks, on which I want to reinforce what the noble Baroness, Lady Tyler, said. Five years after the CMO’s report, we have no strategy. First, will the Government publish a substantive account of progress against his recommendations? Secondly, how will the Government ensure that coastal populations are separately identified? Unless we do that, we do not have the data on which to plan and strategise and see whether improvements can be made. Thirdly, will the department work across government to develop and test commissioning prevention workforce models suited to the distinctive geography and needs of coastal communities? I would be very grateful if my noble friend would agree to meet the noble Lord, Lord Patel of Bradford, to discuss this further, because it is an important consideration.

My Amendment 11 relates to the terrible distribution of GPs in England currently and asks for a much more equitable distribution. I am grateful to the noble Baronesses, Lady Gerada, Lady Hodgson and Lady Manzoor, for their support. Last week I was very fortunate to have a meeting with Minister Dame Diana Johnson and her officials, which I found extremely helpful, and I was grateful to her officials for the way they have been prepared to communicate on this.

This morning, the RCGP published the State of General Practice 2026 report. Chapter 4, about fair and sustainable general practice care—equitable care—makes clear that action is needed. One area where I believe we need action is what the noble Lord, Lord Darzi, described as

“huge and unwarranted variations in the number of patients per GP”.

Data from the NHS general practice workforce team shows that the national average list size of fully qualified full-time equivalent GPs hovers at around 2,200 patients. John Gooderham, a retired civil servant who once worked for me, undertook a number-crunching exercise showing that the differences in average list sizes are almost unbelievable. His evidence, which was published by the Institute of Health and Social Care Management, showed at least 20 areas with an average list size ranging from 8,300 to 4,400 patients, almost four times as many as the national average. All of them are clearly severely underdoctored. At the other end of the scale, there are 20 areas with an average list size ranging from 1,000 to 1,444 patients.

The trouble is that there seems to be no approach or system to rectify this. We used to have the Medical Practices Committee, which was set up by Nye Bevan in the 1946 Act and lasted until 2001. I have to confess that I took through the legislation abolishing the MPC. Mea culpa—it was a mistake. At the time, the line that I took—I looked it up—was that area health authorities would sort it all out. Where are area health authorities? They did not, and none of their successors has. I think we need to go back to a system that identifies areas that are overdoctored or underdoctored to consider how we can justify this situation. It cannot be allowed to continue. I know that officials feel that the kind of MPC system we had is not fit for today’s more modern circumstances, but one way or another, either through financial incentives or through some restrictions, we have to do something about this. I hope the Government will be sympathetic.

[Baroness Manzoor (Con)]

Noble Lords will know that I am passionate about improving the health of all. The National Health Service is the National Health Service, not the ill service. So many disadvantaged, marginalised groups are not receiving the care or the health that they need. I will not go back into the disparities and the health inequalities. I have put my name to the amendment from the noble Lord, Lord Patel, who spoke very clearly. It is a simple amendment but would be a pivotal, key amendment to the Bill.

I also support the amendment in the name of the noble Lord, Lord Hunt, because without having the first line of defence of GPs, marginalised groups do not have the access to doctors that they desperately need. Everybody knows the effects of inequalities on the economy, the NHS and individuals. The Government have a great opportunity to enhance the Secretary of State’s power and strengthen it, rather than transfer the current power.

As I indicated earlier, in my region we had a duty to bring down inequalities in a deprived area. I worked closely with Alan Milburn and other Ministers, including the then Prime Minister, Tony Blair. It worked when that key emphasis, monitoring, duty and strategy were put in place. We need a health strategy, as the noble Lord, Lord Patel, indicated. I leave the question on the table for the Government. This is a fantastic opportunity. It is not about all the structural change that we have been talking about; this is about making a real difference to people’s lives and to the health of our nation.

19:00

[Baroness Gerada (CB)]

My Lords, I rise to support Amendments 11 and 14 in the names of the noble Lords, Lord Hunt and Lord Patel of Bradford, who also asked me to speak to this amendment.

First, I want to say that I find it helpful—and, in listening to this debate, even more helpful—to separate out health inequalities and healthcare inequalities. Health inequalities are due to the social determinants of ill health, as we have heard, such as housing and employment, which require cross-government involvement to address—the lowering of the unwanted teenage pregnancy rate was a fabulous cross-government initiative that had fabulous outcomes—while healthcare inequalities are due to the distribution of healthcare services, which is what I am going to address. I get very confused if I do not separate out those two, and I think sometimes we get in a muddle, because it is not for the NHS to deal with housing. I take the point about Bromley-by-Bow, but the NHS is there to deal with health, ill health, prevention and so on, although of course it should be involved in cross-government work.

I shall start my speech with a GP. In 1971, Julian Tudor-Hart, a fabulous Welsh GP who worked in a mining village in south Wales, wrote a pivotal paper in the Lancet. In it, he described what he called the inverse care law: the availability of good medical care tends to vary inversely with the need for it. Put simply, those who need care are least likely to receive it. That was some 50 years ago, and I would love to tell the House that it was now a historical curiosity, but it is not. If anything, that situation is getting worse. I shall talk about two particular places where we see that most clearly, general practice and our coastal towns.

I shall start with general practice. The noble Lord, Lord Hunt, has given some figures, and I am going to highlight a few more showing why it is so important to have an equitable distribution of general practitioners. Many of the indices of ill health are due to the drop in numbers of GPs. If noble Lords want to debate with me about that claim, I can show that there is an absolute line towards that.

As the noble Lord said, this week the Royal College of General Practitioners published—the first time it has ever done so—its State of General Practice Report 2026. We have to take its findings very seriously if we are going to address our population’s needs. To pull out just one figure from the report, which the noble Lord mentioned, as of September 2026 there were only 36 more full-time equivalent GPs than in September last year—so slightly better than when I made my speech at Second Reading, but not much. British Medical Association data shows that in the same period the number of hospital doctors has grown by nearly 50%. Those figures are reflected in the number of patients GPs care for, such that the average number of patients per full-time GP has gone up by 12% and at the same time, according to data in the British Medical Journal, the number of patients per consultant has fallen by 18%.

GPs are doing their best to meet the demand. Over the last 12 months, approximately 388 million appointments were carried out in general practice—by the whole team, but largely by GPs. Some 45% of those appointments were booked for the same day, 82% of them within two weeks, and 60% of them were face to face, excluding home visits. That is tens of millions of appointments more than before the pandemic.

The Government have rightly said that care should move out of hospital and into the community, but we have moved the patients without moving the resources. So it is perhaps not a surprise that the Royal College of General Practitioners survey showed that three-quarters of GPs say their workload is compromising patient safety, while the GPs themselves have the highest burnout rates of all the professional groups.

Here is the part I find difficult to understand. Thanks to government initiatives, we now have over 5,000 doctors in general practice training, the highest figure for years, but BMA analysis shows that half of those who finished training between 2018 and 2024 were not working in a GP practice a year later. It is not that the practices do not want them; they just cannot afford to employ them. This is the contradiction at the heart of the problem: demand is rising yet the workforce has not kept pace. As Tudor-Hart predicted, those who lose out most are those in most need.

According to the Health Foundation, after accounting for increased workload and higher health needs in poorer communities, practices in deprived communities receive roughly 7% to 10% less funding than those in affluent areas—and I now know where, in a way, that has come from, and I thank the noble Lord, Lord Hunt. We are not just failing to tilt the playing field towards needs; we are tilting it the wrong way. That is the case for Amendment 11. If we are serious about reducing healthcare inequalities, general practice distribution must reflect the population’s needs.

That brings me to Amendment 14. As we have heard, the Chief Medical Officer’s report on coastal communities found that those living in seaside areas have shorter lives and spend more of those years in poor health. We have heard about the challenges they have—poor transport, geographical isolation, older population. Noble Lords might expect the health service to send more staff to areas with higher levels of illness, such as coastal areas, but too often it is the opposite. In Hastings, a lovely place, each GP cares for more than 3,700 patients, the highest number in England. In Kingston upon Hull, which again is a lovely place, there is roughly one GP for every 3,000 patients, but in Kingston upon Thames the figure is roughly 1,900—similar names but very different experiences.

The GPs and nurses who work in those places describe it vividly. In Skegness, an area where I spent many of my childhood holidays, staff told researchers about constant firefighting, burnout and isolation, and about patients who could not get their appointments because of poor transport. The problem extends beyond general practitioners to community nursing, where recruitment and pay parity have fallen even further than for GPs.

The evidence is clear that reducing healthcare inequalities requires services and workforce planning to reflect the needs of the communities they serve. That is why Amendment 14 matters. It would explicitly place the need to reduce healthcare inequalities between coastal and inland communities within the Secretary of State’s duties under the Bill. Funding must reflect the health needs of the population, not merely the number of patients on a practice list. As care moves out of the hospital and into the community, staff and resources must move with it.

These amendments are not seeking preferential treatment for GPs. They are seeking fair treatment according to need. Robust evidence spanning more than 50 years shows that more GPs per head of population means better health outcomes, fewer premature deaths, a better patient experience, more preventive work and a lower cost to the NHS.

I hope the Minister will recognise that these amendments would give practical effect to the Bill’s ambitions to reduce healthcare inequalities. The inverse care law was identified 50 years ago but we should not accept that it remains patients’ experience today. They did not choose to live in the deep end, but we can choose whether to leave them there.

[Baroness Hodgson of Abinger (Con)]

I too put my name to Amendment 11. I do not want to repeat everything the noble Lord, Lord Hunt, and the noble Baroness, Lady Gerada, have said, but it is so important that people have access to a GP. Too often we hear that people cannot get to see their GP. That is one reason why A&E departments in hospitals are becoming overwhelmed—because people then go there. I too am concerned that GPs are being asked to see far too many patients. Many patients cannot be dealt with in just 10 minutes, and the stress of all this is creating burnout for GPs, as we have heard. So please can we ensure that everyone has access to their GP without having to wait weeks or fight with the receptionist?

Patients need continuity of care. We all know that, when GPs know their patients, the outcomes are hugely better. I am not medical, but it is common sense that if a patient can get to see a GP quickly, things can often be resolved sooner and conditions picked up earlier, making treatment easier. We need to ensure equality of access. If we can get the GP system functioning better everywhere, that will help to deal with some of the enormous strain placed on other parts of the national healthcare system at the moment.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I am very pleased to support many of the amendments in this group, and I absolutely acknowledge that there is a difference between health inequalities and healthcare inequalities, but both need to be addressed. I shout out to my own GP practice, Chatfield Health Care, which is utterly brilliant and serves a very mixed economy. The noble Lord, Lord Patel, rightly said, in my view, that unless we address the issues pertaining to inequalities, then the healthy survival of the NHS is in question. Currently, I do not think that we are in a fit state to address the inequalities; this Bill is a golden opportunity to do that, and we absolutely must.

I go back to the Labour manifesto of 2024, which promised

“a fairer Britain, where everyone lives well for longer”.

It promised a shift to prevention and that Labour would halve the gap in HLE between richest and poorest regions through tackling the social determinants of health. This was followed up by the 10-year plan. Both of these have an excellent vision, but I fear that, too often, short-term pressures hinder long-term plans. I regret, for example, that the Mission Delivery Unit was disbanded and that long-term prevention no longer seems to be prioritised. That is why it is crucial that in this Bill we strengthen the duties on health inequalities.

I welcome the Government’s devolution agenda, about which we hear so much, including the English Devolution and Community Empowerment Act 2026 that we passed earlier this year, and the strong duty in that Act on strategic authorities to improve health and tackle health inequalities. The amendments before us today would place the equivalent duties on the Secretary of State for Health, with a requirement that Ministers across government have regard to them.

I agree that health inequalities should be addressed locally and that power being devolved to strategic authorities and local authorities will help enable those who are well placed to address the wider determinants. However, in a devolution-first world, the responsibilities and budgets of Whitehall departments mean that central government has a pivotal role and responsibility in addressing the many policies which have a profound impact on health that have been mentioned in this debate. Your Lordships supported and achieved parity of esteem for mental health, and the duty before us today would create a parity of esteem for prevention. It would be embedded as a shared goal across national, regional and local government. It is crucial.

The Government have made great progress in some areas, such as the smoke-free generation or ending the two-child limit. These changes will have a long-term benefit for health and reducing inequalities, but they do not represent a strategic across-government approach. In other areas, there have been good ambitions, such as a healthy food standard, but implementation has been slow and there have been loopholes. Such a patchy approach will not achieve health in all policies and will allow inequalities to keep widening. The approach must be across government.

As the noble Lord, Lord Patel, and my noble friend Lord Hunt said earlier, from 2000 to 2010 we made great progress thanks to that cross-government approach. Indeed, the Prime Minister was a part of that Government and in 2010 as Secretary of State he launched the Marmot review and subsequently made Greater Manchester the first Marmot city region. He has pledged to tackle regional inequality with good growth in every postcode, as we know, and to rewire the state in favour of prevention. We have heard many facts and figures today which demonstrate that this pledge must become a reality if our country is to fulfil its potential. I pay tribute in passing to Sir Michael Marmot, whose work is transformatory.

My noble friend might well speak of additional burdens, but she herself tabled amendments to the Health and Social Care Bill in 2022 requiring consultation and regular planning and reporting on the health and social care workforce. These amendments take a similar approach. They do not create a lot of processes. In fact, they codify what Ministers have already committed to but which is too often deprioritised. There are several precedents for creating accountability frameworks for cross-government agendas that are much more cumbersome, I would say, such as the Climate Change Act and the Child Poverty Act—not that they are not important; they certainly are.

My noble friend has certainly been in listening mode, and it is a pleasure to have interacted with her in so many meetings. I strongly urge her not just to listen to the arguments made this afternoon but to act and to amend the Bill so that we have a duty to address inequality and that it is done on a cross-departmental basis. It will make such a difference to the life and the health of the citizens of our country and consequently to the economics of our country.

19:15

[Baroness Nargund (Lab)]

My Lords, it is an honour to follow my noble friend Lady Royall. I support Amendment 18 from the noble Baroness, Lady Tyler, to publish a cross-governmental strategy to reduce health inequalities in England. This debate has been extremely humanitarian because addressing health inequalities is a matter of social justice and human dignity.

Health is not created in hospitals or GP clinics; it is created in homes, workplaces and our communities. Health is so fundamental, as Martin Luther King said:

“Of all the forms of inequality, injustice in health is the most shocking and the most inhuman”.


That is what we are talking about—addressing something of a humanitarian nature by addressing health inequalities around our country.

The noble Baroness said about the NHS being criticised. It has often been criticised as not being a national health service but a national sickness service. If we really want to transform our NHS to become a national health service, we have to address health inequalities. These do not lie within hospitals or clinics but in our society and the social determinants of health.

I declare an interest as a founder and trustee of the charity the Health Equality Foundation which works in this area. I also have had the honour of working with Sir Michael Marmot in helping to address the social determinants of health. One of the greatest challenges we face is this nearly 20-year gap in healthy life expectancy, and this cannot be addressed by one department alone nor simply by hospitals. Like the child poverty strategy, we need a whole-government approach to tackling the wider determinants of health—where we are born, how we live and the conditions in which we grow up—which account for 80% of health outcomes.

After having served in the NHS for nearly 40 years, with over 30 years as an NHS consultant, I have treated the consequences of inequality, but I was not able to address the causes of inequality. We have a huge opportunity to address that. I welcome the Government’s manifesto commitment that my noble friend Lady Royall mentioned and the 10-year plan commitment to address health inequalities and the wider determinants of health around our country. The commitment to address health inequalities—not that I know previous Health Bills well—has never been stronger.

The economic case is as compelling as the moral one. If the north of England achieved the same health outcomes as the rest of the country, it could add £18.4 billion to our economy each year. Poor health reduces productivity, increases welfare spending and constrains growth. We know if we want good growth in every postcode, we need good health in every postcode, not just good healthcare in every postcode, which we all know is also essential.

I support this amendment from the noble Baroness, Lady Tyler, because of the need for a cross-government strategy. I have previously spoken in this Chamber about the need for a cross-government taskforce or board; I have also written about that. I believe a cross-government strategy and a taskforce are needed to address our health inequalities and that that taskforce would go beyond this to tackle wider and general determinants of health.

If we want to seriously address this, we must have a cross-government strategy. I recognise the important work already undertaken by the Government in this Bill and the 10-year health plan, but given that many of the underlying causes of poor health sit outside our health service, has the Minister given any consideration to developing a cross-government strategy and potentially a taskforce similar to the one created in respect of the child poverty strategy to address the wider determinants of health? Are there any lessons from that approach that could be applied to tackling wider health inequalities? I am really honoured to have spoken in this debate.

[Baroness Lister of Burtersett (Lab)]

My Lords, I am honoured to follow my noble friend Lady Nargund. I have added my name to a number of the amendments in this group calling for a clear duty on the Secretary of State to take action to reduce health inequalities and produce a cross-government health inequalities strategy. I also support the other amendments on this theme, including that in in the name of the noble Baroness, Lady Bennett of Manor Castle. As we have heard, her amendment makes specific reference to inclusive health groups, including Gypsy, Roma, and Traveller communities, who experience some of the poorest health outcomes of any group in England, as the noble Baroness, Lady Jones of Moulsecoomb, spelled out.

As Just Fair points out, there is a right to health under the International Covenant on Economic, Social and Cultural Rights. In its 2025 concluding observations, the UN Committee on Economic, Social and Cultural Rights raised a number of concerns about the provision of health services in the UK, including inequalities in access to care, as we have heard about.

At Second Reading, I and a number of other noble Lords spoke in favour of a clear duty on the Secretary of State to tackle health inequalities and a cross-government health inequalities strategy that would underpin the preventive approach that the Government, rightly, initially favoured and, indeed, that the Chancellor referred to in his Budget speech today. Our interventions reflected calls from a wide range of health and other bodies, many of which support the Health Equals campaign to put tackling health inequalities on a statutory footing and to reboot the Government’s emphasis on a preventive approach. It also reflected the position of the Health and Social Care Committee in its scrutiny report on the Bill.

The Government themselves have emphasised the importance of addressing health inequalities in their child poverty strategy, as I pointed out at Second Reading. Indeed, the strategy declares that addressing healthcare inequality is at the heart of their health mission. Moreover, in September, the Minister for Women and Equalities, in announcing the establishment of a new class unit, described it as

“a pivotal step in embedding a focus on socio-economic inequality into the heart of government”,

as part of their drive to tackle entrenched inequality. Given all that Ministers have said about inequalities, I am puzzled as to why they seem so reluctant to translate this commitment to tackle entrenched inequality into a statutory duty in this key legislation.

In the Commons, Minister Smyth failed to give a convincing explanation as to how mere empowerment is more effective than a duty to address health inequalities, which she herself said remained a government priority. However, it might not be a priority for a future Government, so warm words are not enough. In the Second Reading debate in your Lordships’ House, my noble friend the Minister reiterated the Government’s commitment to working for greater equality but did not engage with the arguments put by a number of us and explain why a power is better than a duty to achieve this. I therefore hope that she has been able to reflect on what was said and on the growing pile of evidence on health inequalities, especially among children, some of which we have heard about today, and that she will be able to respond more positively and commit to bringing forward a government amendment on Report that meets the objectives of the various amendments debated today.

[Lord Lansley (Con)]

My Lords, I may be the first speaker not to have signed any of these amendments, but that does not mean that I do not agree with them; a great deal has been said with which I agree. The importance of this debate can hardly be overstated.

I just want to contribute one thought, which is that in taking all these issues and understanding how they relate to this Bill, we have to put it in the context of what is already in the National Health Service Act. I want very quickly to outline that.

The Bill before us is an improvement on what is in the NHS Act as far as the Secretary of State’s duties are concerned, because it extends the duty from equal access to healthcare services and facilities to seeking to reduce inequalities and securing equity in outcomes from healthcare services. That is what is in the Bill; I think that is a significant improvement. The Bill focuses at this point on what the National Health Service is doing to secure the prevention of illness and the promotion of successful treatment. It is not about the improvement of public health at that point.

The noble Baroness, Lady Tyler of Enfield, talked about the Bill transferring a duty to the Secretary of State. In fact, the NHS Act has the same duty on both the Secretary of State and NHS England: they are concurrent duties. Therefore, we are not transferring the duty; this is not part of a transfer from NHS England to the Secretary of State.

Under Section 2A of the NHS Act, the Secretary of State has a duty for the protection of public health, which are all those things to do with vaccination, immunisation, et cetera. Section 2B, which was inserted by the 2012 legislation, as my noble friend on the Front Bench will recall, inserted into the Act a duty as to the improvement of public health, and that is on both local authorities and the Secretary of State. It is not, I think, phrased as we would want it to be; more needs to be done to look at that.

I suggest—and this picks up the point made by the noble Baroness, Lady Royall of Blaisdon—that when we talk about wider determinants of health, we are looking at a strategy that relates not only to the Secretary of State—i.e. to the Government—but to local authorities, and she made that point very rightly. But it is in the NHS Act. Local authorities have a duty to improve public health in their area and take such appropriate steps as they can to achieve that, and the Secretary of State has such a duty to improve public health in Section 2B—unaffected, as I understand it, by this Bill. Therefore, when we come to look at it on Report, I hope that those who are thinking about how we might create the right strategy for the improvement of public health do not just think that it is done by attaching it to the responsibilities of the Secretary of State in relation to the NHS but also look at Section 2B.

[Baroness Royall of Blaisdon (Lab)]

My Lords, I am grateful to the noble Lord for giving way. I recently read Section 2B of the NHS Act. I think one would find that it states that local government and strategic authorities “must” improve health and reduce inequalities, but the Secretary of State only “may” improve health. I think that is very interesting to look at. Perhaps that is a wrong that we ought to right.

[Lord Lansley (Con)]

The noble Baroness is absolutely right: local authorities “must” take such steps as they consider appropriate; the Secretary of State “may” take such steps as they consider appropriate. I think I was right in saying—and she has illustrated it—that we can improve what is in Section 2B. I would just make the point that, when we come to Report, it is necessary not only to look at what is in this Bill but to look at how the improvement of public health is promoted through the NHS Act, including Sections 2A and 2B.

19:30

[Baroness Thornton (Lab)]

My Lords, I do not intend, by and large, always to follow the noble Lord, Lord Lansley, if I make a remark to your Lordships’ House, and I will not go into the reasons for health inequalities, because they have been spoken to very adequately by the noble Lord, Lord Patel, and my noble friends Lady Royall, Lord Hunt and Lady Nargund. However, I want to say something about social care because, although the noble Lord, Lord Lansley, is quite right about public health and the need for prevention, none of this is going to work or be delivered—I make no apologies for saying this and I will keep saying it—including the 10-year plan and integrated care, unless we also address the issue of social care inequalities. As I am chair of the Social Care Institute for Excellence, the Committee would be expecting me to talk about that.

We recently did research, which has been published, about the inequities experienced by people who use social care. I thought it might be useful to remind the House what that said, because it will sound very familiar when we are talking about health inequalities. It was about people with lived experience, because our work in SCIE is based on people with lived experience, and co-production. It said:

“These policy and practice implications are reflected … by participants: a named point of contact to help them navigate the complex system … better continuity of carers to improve the quality of care and reduce the burden of having to explain one’s needs”,


as we hear time and again,

“clearer and more proactive information to ensure everybody is aware of their entitlements … investment in the workforce to encourage greater professionalism and retention … more consistent provision across areas to reduce the postcode lottery”.

We could be talking about the inequalities we have just been debating; the same applies in social care. The reassurance I seek from my noble friend the Minister is that that will be recognised as we go through this legislation.

[Lord Mawson (CB)]

My Lords, I found this an interesting debate, and I am sympathetic to the amendment of the noble Baroness, Lady Bennett, and particularly that of the noble Lord, Lord Patel, because he is right that very little is actually being learned. My colleagues and I have listened, over the years, to lots of conversations about health inequalities. When you spend your life in very challenging housing estates and see very little changing, you know about the distance between all the words and the practice.

That is why, many years ago, we decided to focus on practice and the doing of things, rather than the talking about things. We began to realise what every parent knows: that you only really learn by doing. When I started to work with GPs, originally in east London, they began by telling me that was how you became a GP. You saw one, you did one and then you taught one; it was a very practical matter. Businesses and entrepreneurs nowadays know that you learn by doing things. Yet in the state, which often feels so out of date in the NHS, there is no learning by doing culture. There is a learning by writing very fine reports, often at 60,000 feet, that seem very unengaged with practice.

Over the years, it has been interesting to observe what happened through practice. The Bromley-by-Bow model is well known, so I will not use it, but the noble Earl, Lord Howe, knows that I was also responsible for the transformation of a street following a murder and 10,000 illegal injections being given out in a housing estate. There were some terribly violent circumstances going on at the time. When I brought the first key people on the street together, all of them—the GP, the school and the housing association—were saying, “We cannot deal with this on our own. We need to do it together. These things are so interconnected”, and we built together the St Paul’s Way Transformation Project, which started with nothing and led to a new £40 million school, a £16 million health centre, 600 homes and now a new primary school.

We joined it up, and Professor Brian Cox and I led our 14th science summer school in June this year, with a masterclass at the end of it on quantum physics, for the children from the same housing estates. It is the same children and same families, and now they have one of the best performing schools in Tower Hamlets. The noble Earl, Lord Howe, helped us greatly at one key point with learning by doing, when he met the whole group—housing, health and education—when the NHS was getting in the way of us completing on the deal for the health centre. He was very helpful in enabling that to actually happen.

It was Duncan Selbie, the chief executive of Public Health England in 2015, who gave me £20 million and said, “Andrew, take this culture that you’ve been developing into the north of England”. We built 10 learning by doing innovation platforms in Rotherham, Bradford, Doncaster and Bootle, all of which were about bringing people together to learn about these matters. It was interesting that when I met the public health officials in each of these places, who were lovely people quoting all the same data that I had heard many times before, and said to them, “What are you actually going to do about that data?”, there was absolute silence. It was not their fault. They did not have the skills to know how to turn fine words into practice for some of the most challenging communities in this country.

It is my view that one of the things being missed in this moment is the serious need to get real about innovation and learning by doing. My colleagues and I—I declare my interests—are at the moment creating at place, on the ground, with local people and professionals, what we call these learning by doing innovation platforms, so that we bring together the actual GP, business person and local resident, and you begin to explore these issues together because in the modern world, health is everybody’s business. It is not just a matter for GPs. It is interconnected and we need to explore what that means.

My concern about where we are at the moment in discussing this Bill, which is a fantastic opportunity for this Government, and this country, to move into a form of health that is of this century and not last century, is that we are going to end up building a lot of biomedical boxes around this country that do not explore these interfaces in some of our most challenging communities. The noble Lord, Lord Patel, is right; we need to worry about why he is right and why things are not being learnt.

I finish with the thought that it is our experience over the years that, sadly, we have to say that, in so many respects, the NHS is not a learning organisation. We must have hosted 70 Government Ministers to our work over the years. They all come and say, “Wow, this is fantastic, we need to do more of it”. I can name the four who did anything practical about that, and the other 66 sit on a list in this pocket. This is not to do with bad people. It is about whether, as a nation, we are now going to get upstream into prevention and health creation and create a learning by doing environment in which we all learn together, and in which local people are part of all of that process.

[Baroness Pidgeon (LD)]

My Lords, this is a very important group of amendments, and it has been a really excellent debate. One of the most pressing issues facing us is the widening gap in health outcomes between different communities. Healthy life expectancy has fallen in recent years and the gap between the most and least deprived areas of England, as we have heard, now stands at almost 20 years.

The point made earlier by the noble Lord, Lord Crisp, when he talked about the role of the department being one of leadership for health across government, not just running the NHS, is really important as we approach this group of amendments. We have heard clearly that the current legislative framework places relatively weak duties on government to address these wider determinants of health and tackle inequalities.

The House of Commons Health and Social Care Select Committee, in its scrutiny of the Bill, called for a stronger focus on improving the nation’s health and tackling inequalities, emphasising the need for clearer accountability and a more robust approach to prevention across government. Many of the amendments in this group would help to achieve that aim by ensuring that reducing health inequalities becomes a central objective of health policy, and that progress is measured and reported transparently.

My noble friend Lady Walmsley’s amendments, spoken to by my noble friend Lady Tyler, and Amendment 7 from the noble Lord, Lord Patel, would strengthen the duty on the Secretary of State to take steps or action, rather than simply “have regard to”. That is really important. Amendment 14, tabled by the noble Lord, Lord Patel of Bradford, and supported by so many Members of the House today, would require the Secretary of State

“to have specific regard to reducing inequalities”

in coastal communities. The point has been made clearly about the added complexities for such communities, whether those are workforce related or in local service provision. Those are really important.

My Amendment 20 looks at health inequalities in urban areas and requests a strategy and an annual report. Impact on Urban Health, which is part of Guy’s & St Thomas’ Foundation, recently reported its State of Urban Health research and found that preventable mortality is 2.7 times higher in the most deprived urban neighbourhoods in England than in the least deprived. Urban areas also face some of England’s starkest health inequalities, with people living just streets apart experiencing significant differences in health. You have only to look over the river to the London Borough of Lambeth, where Impact on Urban Health is based: females who live just over a mile apart face an eight-year gap in life expectancy. As we have heard, these inequalities are driven by unfair and avoidable differences in everyday environments. These include exposure to air pollution, differences in housing quality and access to healthy, affordable food. I pulled this area out for specific attention: rather like the coastal communities amendment, it needs specific action.

My noble friend Baroness Tyler spoke strongly to Amendment 18, which would require a cross-government health inequality strategy and subsequent annual reports to Parliament on progress. That would focus minds and energy across government and would address the key point from the Health and Social Care Select Committee, as well as many of our suggestions in amendments and today’s debate.

If we are serious about narrowing the gap in healthy life expectancy and giving everyone the opportunity to live a healthier life, then action on the wider determinants of health and tackling health inequalities must sit at the heart of the Bill, not at its margins. I look forward to hearing the Minister’s response.

[Baroness Cash (Con)]

My Lords, I begin by thanking all noble Lords who tabled amendments in this important group and for the high quality of debate. At this time in the evening, it falls to me to be as brief as possible. As the quality of debate and the points made have been so thorough, I will try not to repeat anything.

We are all very much agreed: from these Benches, we have heard from the noble Lord, Lord Lansley, from the noble Baroness, Lady Manzoor, and from the noble Baroness, Lady Hodgson. We care a great deal about the inequalities in health outcomes in this country, but I am very grateful to the noble Baronesses, Lady Gerada and Lady Royall, for drawing the distinction between healthcare inequalities and health inequalities. It is important, and it is important for the purpose of the Bill and the duties that ought to be placed on the Secretary of State for Health.

It is incredibly challenging and painful to hear the data regarding ongoing inequalities. We know, of course, that healthcare is not the reason why it is in that state. The factors that play a part sit in different departments, which is why these Benches welcome the amendments which ask for a strategy. I hope that the Minister will consider joining up some of the significant work being done by the Government in the Fonagy review and the Milburn review to look at all these issues together.

It would be helpful to hear from the Minister about the specific actions the Secretary of State would be expected to undertake to ensure the duty as it is currently drafted, and how Parliament would be able to assess those decisions. We have heard from the noble Lord, Lord Lansley, about how we might improve on the current legislation, and it is important that we hear how that might be done. The inequalities in general practice are significant and challenging, and I look forward to hearing from the Minister about the Government’s plans to address them, such as through incentives to serve in different areas, targeted work plans and ensuring that enough training, development and recruitment is going on in those areas. I hope that all these issues will be subject to consideration by the Minister.

We cannot expect to reduce health inequalities without addressing these disparities in primary care. We look forward to hearing what might be done and what might be included in this Bill to do that. In the end, we must judge success by whether patients have access to the healthcare needed at the point of delivery. I look forward to the Minister’s response.

19:45

[Baroness Merron (Lab)]

My Lords, I am grateful to the noble Baroness, Lady Jones, for opening the debate on this group, starting with the amendment laid in the name of her noble friend, the noble Baroness, Lady Bennett. I am grateful to all noble Lords for their consideration on a topic that is key to this Bill and to all our work. I will return to this, but it includes the 10-year health plan, which provides the framework for all that we do.

I start with Amendments 6 to 11 and 13 to 20. I assure your Lordships of our commitment to tackling inequalities. We have debated this several times in this Chamber and rightly so. I certainly agree with the comments made, including those from the noble Baroness, Lady Cash. This is about people’s ability not just to access services but to achieve the right outcomes for them regardless of who they are, their background or where they live.

I turn to Amendments 8 to 10, tabled by the noble Baroness, Lady Walmsley, and spoken to by the noble Baroness, Lady Tyler, and Amendment 7 in the name of the noble Lord, Lord Patel. These test whether the duty on the Secretary of State is strong enough. It is right to discuss that point. I appreciate the intention—which was emphasised by my noble friends Lady Royall and Lady Lister, and the noble Lord, Lord Lansley—to ensure that we are taking action, because that is ultimately what we are here to do. However, I would caution against amending the Bill in the way that the amendments seek to do. As a number of noble Lords will be aware, the “have regard” formulation in legislation has a number of precedents across the statute book, and it is familiar to government departments and to decision-making in the public sector.

There was an exchange between the noble Lord, Lord Lansley, and my noble friend Lady Royall over Sections 2A and 2B of the NHS Act. I tread with some trepidation at this stage, but we do not believe that it is necessary to change “may” to “must”, certainly for the duty in Section 2B. This is for the reason I have just outlined about risking confusion because it is moving away from the usual way of doing things. It would also potentially reduce the ability of Ministers to make decisions about priorities. There is no practical intention to reduce the importance of tackling inequalities. The noble Baroness, Lady Gerada, has moved from her place.

[Baroness Gerada (CB)]

It was cold down there.

[Baroness Merron (Lab)]

I am sorry to hear that it is cold, but I am glad the noble Baroness is here. I appreciated the useful distinction that she drew regarding what we are talking about when we talk about inequalities.

Amendments 18 and 19, tabled respectively by the noble Baroness, Lady Tyler, and the noble Lord, Lord Patel, have regard to new strategies for tackling health inequalities. I know that your Lordships’ Committee is aware, but it is worth saying again that we remain absolutely committed to our comprehensive 10-year health plan. It was drawn up with a very wide range of input and, importantly—as has been referred to on this group and elsewhere—it was underpinned by the independent investigation of the NHS by the noble Lord, Lord Darzi. Tackling inequalities is at the very core of the 10-year health plan, which dictates everything that we do. It is therefore important that we focus on practical action rather than diverting towards developing new strategies. To assure noble Lords, I repeat that tackling inequalities is what I call core business; it is not an add-on or a sidecar—it is absolutely key.

The noble Lord, Lord Patel, put a number of observations to me and asked whether I agreed with them. My answer is that I appreciate them all and agree with most. I particularly welcome the acknowledgement by the noble Lord, Lord Patel, the noble Baroness, Lady Manzoor, and a number of my noble friends, of the achievement of the last Labour Government—which was somewhat exceptional in the period we have been talking about. The only point I would make to the noble Lord, Lord Patel, is that when he was running off a list of Ministers at the time, I hoped he might mention me—but I am doing so.

[Lord Patel (CB)]

I was going to do so after I heard the Minister’s response.

[Baroness Merron (Lab)]

I was very proud to have been part of that as Public Health Minister, working with Andy Burnham. But it is not enough to just rest or delight on one’s memories; we must take what worked and bring it into the current time.

I agree with the noble Lord, Lord Patel, that tackling health inequalities is key to not just the NHS but the broader economy—and, of course, the well-being of people. I agree with all noble Lords who said that a cross-government approach is crucial. That is why we are taking that approach, underpinned by the 10-year health plan. Tackling inequalities, for example, informs the key initiatives of the 10-year health plan, such as neighbourhood health centres. On that, we are starting in the most deprived communities. We are not going to the communities that are easier to work with; we are starting where there is the most challenge. I welcome that radical approach.

I believe accountability is extremely important. I assure noble Lords that the department will continue to report on action taken to address health inequalities as part of its annual report, alongside a whole range of published metrics, including the health inequalities dashboard. The dashboard’s measures cover 20 indicators, including—I will give noble Lords a couple of examples —the prevalence of adult and childhood obesity, and healthy life expectancy at birth.

My noble friend Lady Nargund supported the call for a cross-government strategy, which we are already working on. Recent cross-government action in this area includes the warm homes plan, the Keep Britain Working review and the homelessness strategy—all of which speak to the points that noble Lords are calling for. That is one of the reasons why I caution against putting in the Bill a duty to develop some independent strategy, when in fact it is core to what we are already doing.

Amendments 13 and 14 were tabled respectively by the noble Lords, Lord Patel and Lord Patel of Bradford. My noble friend Lord Hunt asked whether I would meet the noble Lord, Lord Patel of Bradford; I would be very pleased to do so, and I open that meeting up to other noble Lords who are interested in coastal and rural areas. Amendment 20 was tabled by the noble Baroness, Lady Pidgeon. These amendments are concerned with tackling health determinants and inequalities in coastal and other areas.

Health is determined not just by our health and care system but by our wider environment. We know that geographical variation has grown over a number of years, and this Government seek to tackle it. That variation runs from housing and employment to education and our local high streets, to name just some. It has informed the content of our 10-year health plan and the overall guiding aim that we pursue: to halve the gap in healthy life expectancy between the richest and the poorest—to which noble Lords referred. That is why we are introducing the neighbourhood health centres, to which I referred, where they are needed most. We are now going further by devolving power to local communities so that those who know their areas best can make sure that the services are there for them. I remind noble Lords that ICB funding allocations, for example, are already adjusted for health inequalities and take account of factors such as an ageing population and deprivation. The Core20PLUS5 approach gives ICBs a range of tools to tackle inequalities, and we will—and do—hold ICBs to account for their progress.

I am grateful to my noble friend Lord Hunt for tabling Amendment 11 on accessing GP services—an area raised by other noble Lords, including the noble Baroness, Lady Gerada. I agree that equitable distribution of GPs is crucial to ensuring that people in all areas get timely access to care. When I say that, I mean not that every area should have exactly the same number but that the distribution should be sensitive to the needs of an area. Progress is being made: there are 2,600 more GPs than in July 2024—the highest figure since 2015; the average number of patients per GP practice is improving; and we continue to boost recruitment through the practice-level GP reimbursement scheme in 2026-27. Because GPs—like other professions —are more likely to practise where they trained, we are delivering 1,000 more GP training practices by 2028, targeted towards the areas of greatest need. We are also reviewing the Carr-Hill funding formula because, to reduce health need, we have to ensure that resources are allocated much more accurately—as noble Lords expect.

The noble Baroness, Lady Hodgson, also commented on this area. We are uplifting the GP contract by £601 million for 2026-27, which builds on last year’s £1.1 billion of additional investment. In the year to August 2026, 15.8 million additional appointments—including Covid vaccinations—were delivered, compared with the previous 12 months. This is the way we are going. When I make these points, I am not saying that the job is done, but I am showing movement and improvement.

20:00

My noble friend Lady Thornton spoke rightly about having regard to social care. I know my noble friend knows this, but adult social care has its own statutory framework under the Care Act 2014, which is separate from the Health Bill. That said, I absolutely agree with her that social care and the NHS are inextricably linked, which is why we have committed to establishing a national care service alongside our National Health Service.

My noble friend referenced his meeting with my ministerial colleague the Minister for Public Health and Patient Safety to talk about concrete actions, which are key, rather than additional legislation. I am glad that he found that helpful and constructive, and I will certainly feed that back.

I am grateful to the noble Baroness, Lady Bennett, for recognising the significant inequalities experienced by a range of inclusion health groups, including Gypsy, Roma and Traveller communities, which the noble Baroness, Lady Jones, spoke to. I know that, had noble friend Lady Whitaker been here, she would have done likewise. Disadvantaged populations, including Gypsy, Roma and Traveller communities, are already explicitly recognised within the NHS’s inclusion health and Core20PLUS5 approaches, and we will continue to deal with this approach.

We should have regard to better data, as has been raised a number of times. NHS England’s ethnicity recording improvement plan is certainly strengthening the quality and consistency of that data, and the Office for Health Improvement and Disparities has established a national inclusion health data and intelligence resource. If I had to summarise my points, I would say that we believe that the existing statutory duties are a more flexible and proportionate basis for addressing these inequalities, rather than specifying individual populations and reporting arrangements in primary legislation.

Amendment 6 was tabled by the noble Baroness, Lady Bennett, and spoken to by the noble Baroness, Lady Jones. I have a lot of sympathy with its intentions, but I believe that a broader duty, as described, is unnecessary. The Secretary of State has an existing duty to take steps to protect the public from disease and other dangers to health, as well as powers to take appropriate steps to improve people’s health—noble Lords have spoken about that. Under Section 1 of the NHS Act 2006:

“The Secretary of State must continue the promotion … of a comprehensive health service designed to secure improvement … in the prevention”—

as called for by noble Lords—

“diagnosis and treatment of physical and mental illness”.

The recognition that health is influenced by a range of socioeconomic factors is very much at the heart of our commitment to achieve a long-desired left shift to prevention.

We have had a wide-ranging debate, and I will of course reflect on the points raised. This Government are committed to practical action, and I have given some examples of that and of the way we are moving. This primary legislation, as currently drafted, gives us the necessary legislative basis for what noble Lords seek. I actually think that our biggest challenge is to deliver that.

[Lord Patel (CB)]

The Minister did what I thought she would do: point to areas in the legislation that might help reduce inequalities in health and in outcome, and therefore inequalities in healthcare provision. She mentioned the 10-year health plan, but she was not able to point to where it says the gap is, which is around cross-government action. Neither did she mention examples in the Bill that demonstrate that there is cross-government action. She said she did not agree with me in one area—maybe it was that one.

[Baroness Merron (Lab)]

Oh, no—I agree with the noble Lord about the need for cross-government action. I simply part company with the idea that it needs to go into primary legislation. That would not be usual, because that is a process. I also referred to examples of where we already have cross-government action to deal with health inequalities, as distinct from healthcare inequalities—the noble Baroness, Lady Gerada, referred to that.

[Lord Patel (CB)]

Why not, when, as she mentioned, the Minister was previously so successful as part of the Government who demonstrated how they could implement cross-government action and reduce inequality?

[Baroness Merron (Lab)]

I am not sure we are that far apart on this. I am just picking up the point about primary legislation, rather than the intent of the noble Lord, which I agree with.

[Baroness Jones of Moulsecoomb (GP)]

I will stand up before anybody else does.

I thank the Minister for her replies; I really admire the positivity in there. I have been using the NHS since 1949, and it is absolutely amazing. My working-class parents were incredibly delighted by its introduction, but I rather suspect that my age cohort has had the best of it—I hope that that is not true. I would love to respond to a lot of the points, including on coastal communities, which often suffer from huge environmental pollution in rivers, along seashores and so on. This has been a fascinating debate, and I can see an exciting Report stage in the offing. In the meantime, I beg leave to withdraw my amendment.

Amendment 6 withdrawn.

Amendments 7 to 11 not moved.

House resumed. Committee to begin again not before 9.07 pm.

Arrangement of Business

Wednesday 28th October 2026 Lords Chamber

Announcement

20:08

[Baroness in Waiting/Government Whip (Baroness Dacres of Lewisham) (Lab)]

My Lords, due to an administrative error, with the exception of the Minister and the noble Baroness, Lady Hoey, speakers in the next debate will have five minutes rather than six minutes. Today’s List was reissued earlier with the correct timings and all speakers have been contacted. I would be grateful if noble Lords could stay close to the five minutes, to ensure that there is sufficient time for the Minister’s response, which I am sure all noble Lords will wish to hear.

Railways (Interoperability in Northern Ireland) (Convention on International Carriage by Rail) (Amendment) Regulations 2026

Wednesday 28th October 2026 Lords Chamber

Motion to Approve

20:09

Moved by

[Lord Hendy of Richmond Hill]

That the draft Regulations laid before the House on 29 June be approved.

Relevant document: 9th Report from the Secondary Legislation Scrutiny Committee

[The Minister of State, Department for Transport (Lord Hendy of Richmond Hill) (Lab)]

My Lords, before I begin, I would like to convey heartfelt condolences on behalf of the United Kingdom Government to the families and friends of those who have lost their lives today in the tragic high-speed railway collision in Spain. Our sympathies are with all those who have been injured or affected by this terrible incident.

The draft regulations, which were laid before the House on 29 June 2026, implement the UK’s obligations on rail interoperability under the Windsor Framework and update domestic legislation implementing the Convention concerning International Carriage by Rail, commonly known as COTIF. The regulations establish the conditions and technical requirements that railway vehicles, infrastructure and component products must satisfy before they can be placed on the market or put into service in Northern Ireland.

Interoperability is about making sure that trains, railway infrastructure and railway equipment can operate safely and effectively across connected rail networks. The interoperability framework in Great Britain is set through the Railways (Interoperability) Regulations 2011. However, during the UK’s withdrawal from the European Union, EU states migrated to a new interoperability framework based on Directive 2016/797. Under the Windsor Framework, the United Kingdom is required to apply this directive in Northern Ireland in so far as it relates to the placing on the market, putting into service and free movement of railway products. The regulations implement that requirement by creating a dedicated interoperability framework for Northern Ireland.

The framework established by the regulations facilitates interoperability between the Northern Irish and Irish railway networks while providing legal certainty for industry. The railways on the island of Ireland are functionally and technically distinct from Great Britain’s, with key differences including the track gauge of five feet and three inches in the whole of Ireland as opposed to four feet and eight and a half inches in Great Britain. The rail technical standards applicable in Britain and Northern Ireland have always reflected these inherent differences, even when the whole UK was applying EU interoperability law. There is, therefore, more practical benefit in Northern Ireland having closer interoperability with Ireland’s railways than with Great Britain’s.

The Northern Ireland Minister for Infrastructure shares this view. The Minister wrote to me about the benefits of aligning with Ireland’s rail technical regime, which range beyond the operation of cross-border services. These include joint procurement of train fleets with Ireland and economies of scale for rail equipment, reducing procurement and operational costs. She said:

“The more fundamental consideration is whether the conditions exist to support the long-term development of an integrated rail network across the island of Ireland. The standardised regulatory approach currently provided through the Windsor Framework creates an enabling environment for joint investment, shared procurement and coordinated railway operations. This is particularly important in the context of the recommendations emerging from the All-Island Strategic Rail Review, itself a key recommendation of the Union Connectivity Review”.


Indeed, the joint procurement of the fleet of eight new trains for the Enterprise Service between Belfast and Dublin, due in 2030, a joint service between Northern Ireland and Irish Rail, was facilitated and made cheaper because there was only one technical regime between the two countries and one under which the successful supplier, which comes from the European Union, is familiar with. This legislation will therefore help the democratically elected Government in Northern Ireland to achieve their strategic policy aims in rail.

I turn to the issues raised during parliamentary scrutiny. The Joint Committee on Statutory Instruments considered the regulations and did not draw them to the special attention of either House.

The Secondary Legislation Scrutiny Committee raised several questions regarding implementation, consultation and the wider policy context, and I will address those matters now. The committee questioned the period between the UK’s obligation to implement these requirements, arising under the Windsor Framework, and the laying of these regulations. The UK had not implemented this directive before leaving the European Union. As a result, introducing these arrangements has required careful work to ensure that Northern Ireland and Great Britain can continue to operate effectively under their respective rail frameworks. Delivering these regulations required extensive technical and legal work; it required close engagement with the Department for Infrastructure and the European Union Agency for Railways to ensure the new arrangements would operate effectively.

The regulations make changes in a range of technical areas, such as vehicle authorisation, which ultimately relate to rail interoperability and safety. The instrument is technical and legally complex, establishing a complete rail interoperability framework for Northern Ireland to implement the obligations under the Windsor Framework. Substantial implementation work was required to ensure that the regime could operate effectively in practice; this included developing Northern Ireland national technical rules, necessary to supplement the EU technical specifications.

The regulations principally apply when introducing new equipment on the railway or making major changes to existing vehicles and infrastructure. The department is not aware of any such rail project being unable to proceed while this implementing legislation was in development, and the department took steps to ensure this through interim measures, including publishing technical notices specifying the EU rail interoperability requirements applicable in Northern Ireland.

The Secondary Legislation Scrutiny Committee report questions the department’s understanding that legislation was needed. We have always been clear that legislation was needed and have been working at pace to get this right and in place as soon as practical. The department implemented interim administrative arrangements that allowed the new interoperability regime to operate in practice while the legislative framework was being finalised. We also informed the European Commission of this work while the implementation legislation was in preparation; therefore, many of the requirements in the directive already reflect practices and standards in operation in Northern Ireland.

The committee also asked why updates relating to COTIF are being brought forward only now. The amendment reflects the UK’s position following EU exit. While the UK was a member of the European Union, this issue was addressed through the EU’s arrangements. Following EU exit, it became necessary to reflect the UK’s position directly in domestic legislation.

The committee also questioned the decision not to undertake a formal public consultation. The Government carefully considered this issue. These regulations implement obligations that the UK has already entered into under the Windsor Framework and COTIF. There was therefore limited scope to take a different policy approach. While the policy outcome itself was constrained by existing international obligations, the department adopted a targeted engagement approach with those organisations most directly affected by the legislation, including the Department for Infrastructure, Translink, the Office of Rail and Road, the Rail Safety and Standards Board and conformity assessment bodies to inform a practical approach to the legislation. I subsequently also asked the UK industry trade body, the Railway Industry Association, whether its members had reported any adverse effects or expected any in future. They said they had no adverse comments from their members.

I know that the noble Baroness, Lady Hoey, has tabled an amendment of regret relating to the absence of a formal consultation. While, of course, I respect those concerns, the Government’s view is that the targeted engagement undertaken was proportionate, given the nature of the regulations and the limited scope for alternative policy options.

During scrutiny, concerns were raised regarding the existence of different regulatory arrangements in Northern Ireland and Great Britain, including in a submission from Mr Jim Allister MP. I recognise those concerns, but it is important to be clear about the purpose of these regulations. They do not create the United Kingdom’s obligations under the Windsor Framework, which are set out in the withdrawal agreement. These regulations are concerned with implementing these obligations and providing a clear and legally operable framework for industry and regulators.

The department also continues to work closely with the Department for Infrastructure to understand and manage any future impacts arising from divergence between regulatory frameworks in Great Britain and Northern Ireland. I beg to move.

20:18

Amendment to the Motion

Moved by

[Baroness Hoey]

At end to insert “but that this House regrets that the draft Regulations were not subject to a public consultation on the proposed divergence in rail regulations between Great Britain and Northern Ireland”.

[Baroness Hoey (Non-Afl)]

My Lords, here we are again—another SI, another dinner hour. As many of us have warned for some time, until we actually stop allowing a foreign power, the EU, to take over making the rules for part of our own country, we will be continuing with these SIs.

In welcoming the noble Lord to his place, I know his genuine interest in railways, so I imagine he will have read what is actually, I think, the largest ever statutory instrument I have seen. It is a 40-page document with 54 regulations. I know that his opposite number, the noble Lord, Lord Moylan, will also have read it with great interest. Probably both of them could actually recite the technical details in detail. But, apart from 30 minutes in a committee in the other place, this will be the only scrutiny to which this legislation will be subjected to in this Parliament. Once again, we have regulations that will introduce a divergence in law and authority between two parts of our country, and once again without this Parliament making the laws.

The real significance of this strategy instrument is that, whereas today the whole of the United Kingdom is subject to the same law in relation to railways, once these regulations come into effect the country will be divided in two, with one law applying to GB and another law applying to Northern Ireland. The regulations will introduce and give effect to a law made in, as I have said, a foreign Parliament that will be imposed on part of the UK.

The lack of opportunity even to debate these regulations, never mind change them, makes this absurd. It is also constitutionally an outrage that a part of this country should be reduced by laws we do not make and cannot change, and yet that is what we are doing tonight. There has been no consultation. Nowhere else do we legislate without at least the façade of consultation with the public, but when it comes to Northern Ireland, that is always null and void.

Why has there been no consultation? A chat with the Department for Infrastructure, its Minister, and Translink is not consultation. What about all the businesses affected and the suppliers involved? The Government are at least being honest by saying, more or less, that there is no point in consultation. The Minister himself said there was limited scope. It would be a pointless exercise. Of course, the Minister, whether he likes these regulations or not, is obliged to implement them because of the Windsor Framework.

In the other place, the Minister suggested that the debate on these regulations was not the place to raise constitutional questions of disenfranchisement, because Parliament had already voted to adopt the Windsor Framework. The Minister has not said that, but the Minister in the other place was just wrong. I remind noble Lords that we never voted specifically on the Windsor Framework, and any votes have been in relation to different aspects of it through statutory instruments, the first being on 29 March 2023 on the democratic scrutiny legislation. In this context, where is the place to address the constitutional implications of these regulations, if it is not now and in a debate such as this—if not now, when?

We are told, in effect, that we have no choice. What sort of way is that for any Government to run our country—to rule that, in part of the United Kingdom, the law is being changed by some people and an institution that we have no say in? Is it something that other Members would accept for their county or area: that they cannot change the laws that are imposed and they simply have the obligation, as this SI will have, upon criminal sanction, to implement them?

We are creating in these regulations a scenario in which railways will be governed in a part of the UK not by an agency of the United Kingdom but by the EU’s railway agency. When we look at Regulations 28 to 30, we discover that for a supplier in GB to supply any railway equipment to Northern Ireland, it must apply for and obtain a declaration of conformity that it is complying with the handed-down laws of a foreign Parliament. The Government, and indeed the Minister, have not even acknowledged that there will be an impact on businesses in Northern Ireland and GB. We are creating a separate railway regime for Northern Ireland, so businesses supplying equipment to Northern Ireland will have to meet the requirement laid down by the EU. This will lead to additional paperwork, declarations and costs. Will the Minister, when he is summing up, actually deny that there will be extra costs for businesses?

We are seeing a drip-drip moving of Northern Ireland further away from the rest of the United Kingdom. This cannot be allowed to continue. Our railways in Northern Ireland have been safe, despite the many years of the IRA trying constantly to blow them up and block the line from Belfast to Dublin. They go through some of the most beautiful parts of Northern Ireland. I am sure the Minister would prefer to be discussing how we could have them electrified and get railway lines back to parts of Northern Ireland such as Fermanagh, where we used to have them. Instead of discussing what the public would really be interested in, we are discussing this because the Government have lost control of what happens in one part of our own country. It really is shameful. That is why, despite these regulations being technical, unless I hear something very important from Minister, I will be opposing them. They were opposed in the other place. There was a vote in the other place and more than 100 Members of Parliament voted against this statutory instrument.

I am pleased that gradually more and more people are beginning to realise that the Windsor Framework is destroying businesses in Northern Ireland, those that want to work in Great Britain and those that want to go to Northern Ireland, and that we have to do something about it. I beg to move my amendment.

20:24

[Lord Lilley (Con)]

My Lords, I congratulate the noble Baroness, Lady Hoey, on securing this debate. I want to make it clear how offensive regulations of this sort are to all unionists, whether they live in Northern Ireland or Great Britain. It is offensive and unnecessary to have different laws in Northern Ireland and Great Britain, and that those laws should be imposed by a foreign power. It is offensive that there was no consultation and that Northern Ireland electors have no say in their making and cannot reject them. Moreover, it is offensive to electors in Great Britain that some aspects of the laws changed by this statutory instrument apply this side of the Irish Sea. I hope the Minister will confirm that, although he did not bother to mention in his opening speech that he was changing the laws of Great Britain.

In fact, that is the main reason the EU insisted on the Northern Ireland protocol, now rebadged as the Windsor—whatever it is. It wanted to use it and Northern Ireland as a lever to impose EU law on the whole of the UK. I recall attending a meeting at the LSE during the debates about the withdrawal process, at which the EU negotiator said that the EU is a legislative hegemon and intends to remain so. It wants, as an objective in itself, to impose its laws outside its own territory—which is not particularly necessary, but it is what it wants to do.

It is not because, as some of the nationalists and Sinn Féin say, that the objective was avoiding a border between Northern Ireland and the Republic. That was not really the objective; we can see that in these regulations, which actually create a border between Northern Ireland and the Republic. Paragraph 5.5 of the Explanatory Memorandum says:

“A change in area of use will also occur in the case of a vehicle that crosses the border on the island of Ireland”.


It goes on:

“A change of the area of use of vehicles … will trigger the need for authorisation to place on the market”.


It therefore keeps a border in Ireland, from the regulatory point of view, but imposes, as most EU stuff does, additional bureaucratic procedures. Previously authorised vehicles need to be reauthorised, if they change their area of use, and moving from Northern Ireland to southern Ireland is such a change. Even if a vehicle is intended for use only in Northern Ireland, it will still need reauthorisation. It says:

“If vehicles are intended to be used in Northern Ireland only”,


they have to be reauthorised. The only difference is that then the vehicle owner has the option of applying to the agency set up by the EU, or the Department for Infrastructure.

Ministers and noble Lords may be irritated by the stream of regulations and statutory instruments, and the debates that they trigger, generated by the Northern Ireland protocol/Windsor whatsit. They should, however, brace themselves because dynamic alignment, to which this Government are committed—the previous Chancellor in her Mais lecture said she wanted to see dynamic alignment unilaterally applied to virtually every area of trade with the EU—will require us to accept all regulations passed by the EU since we left. We know roughly how many there are because each regulation bears a number. So far this year, it has got up to regulation 2106/26—more than 2,000 have been passed this year. There have been more than 25,000 regulations introduced since we left in 2020, so your Lordships should look forward to a tsunami of statutory instruments and debates of this nature, as we try to absorb in our legislation everything that has happened since we left.

Why does it have so much legislation? It is because it is committed to it; it is what it does. It has had innumerable reports, most recently pointing out that the reason the EU is the slowest-growing continent in the world is that it is overregulated—but it cannot stop itself from doing it. It is what it does, just as drug addicts take drugs. Why we should consider joining such an organisation or unilaterally adopting its regulations and forcing on ourselves the very things that have made it the slowest-growing economy in Europe beats me. We are growing faster than the major countries in Europe thanks to Brexit—let us keep it that way.

20:30

[Lord Bew (CB)]

My Lords, another night, another statutory instrument connected to the Windsor Framework. I fully accept the many frustrations connected with the implementation of the Windsor Framework, which are widely understood in Northern Ireland.

I thank the Minister for his very clear exposition, in many ways clearer than the statutory instrument document that we have in front of us, and substantially so, and I am grateful to him for that. I also accept that the noble Baroness, Lady Hoey, is right: there is a problem in general about the Government’s mode of address and consultation on these Windsor Framework-related documents. As I say, this is not the first, and it will not be the last that we have enjoyed in this Chamber at dinner hour.

This matter of mode of address is important. Let me say one thing that is significant: I understand why it often seems that the problems associated with this legislation are so small—they are problems just for Translink, I think it says at one point. Well, we need to know more about what those problems might be for Translink. Again, the noble Baroness, Lady Hoey, is right that it is not exactly clear what the problems for business are. It may be that they are slight, but it does not matter. The point is that it is a big, politically sensitive area in Northern Ireland. That is the big thing that government has to ask. The Government’s relationship to the Windsor Framework is a problem.

Let us be clear, by the way: the Windsor Framework passed with a larger majority in the House of Commons than the Anglo-Irish agreement of 1985 by some long way and we have therefore to take it seriously, but the Windsor Framework is not simply an agency under which we have to cope with this sort of Euro legislation. It is important also because, as the Command Paper states clearly on page 5, it is an unhooking from the pressure in the earlier phases of negotiation accepted by our Governments—Tory Governments of 2017 to 2019—and documents of withdrawal; that, for example, the British Government will work to create an all-Ireland economy. That is the unhooking. It is very clear on page 5, for example, of the Command Paper that this will be a different path of development for Northern Ireland, a path of development that has been hugely successful. It is widely accepted that after the Belfast agreement, the Northern Ireland region is now the fastest growing, and Belfast is probably doing better than Manchester. Can we get away with saying that? Well, the figures look as if that is the case.

The problem has been that the Government will only come to the House and tell us, “Here is the latest irritating thing we are doing on the Windsor Framework”. The Windsor Framework is something this Government fully support, but they will not draw attention to their major area of success, the growth of Belfast. The debate then becomes so downturned, miserable and depressed. That is why I am talking about the Government’s mode of address on this subject. Just read page 5 again of the Command Paper and add to it something that it does not specifically mention: the defence expenditure of the UK in Belfast. This is the context: Northern Ireland’s economy has rarely looked stronger, and it relates to that key element in the Windsor Framework, which exists along with these myriad other irritations.

I have one final point. I said, “another night, another statutory instrument”, but actually it is not quite the same as before. We are on the eve of some form of reset between the United Kingdom and the EU—I think 20 November is the date. What this will mean, to put this very crudely—it has already been more than hinted at by the noble Lord, Lord Lilley—is that we are all going to become rule takers. In Northern Ireland specifically, let us consider what is proposed—so what one reads about regarding the SPS deal. The United Kingdom Parliament is going to be accepting rules in the same way that the Northern Ireland Assembly has had to do, with one exception, of course: it will not actually have a Stormont brake. That is what the democratically elected Government are moving towards, but the specificity of Northern Ireland’s uniqueness at the present stage, that it alone has to be a rule taker from the European Union, looks as if it is going to change quite markedly, especially when we get into next year and when we read about what an SPS agreement is likely to include.

So, in conclusion, it is not another night, another Windsor Framework statutory instrument; it is the last of an old type of debate.

20:35

[Lord Dodds of Duncairn (DUP)]

My Lords, I appreciate the opportunity to take part in this debate and congratulate the noble Baroness, Lady Hoey, on securing it. It is important to continue to debate regularly laws that apply to part of the United Kingdom, especially when they are set by others and not by the House of Commons, the House of Lords or the Stormont Assembly. When they are set by people who do not live, vote or have any role in the United Kingdom, it is fair that we should examine in great detail what these laws are all about.

I listened carefully to the noble Lord, Lord Bew, and I obviously have great respect for his views, but I remind him that, in terms of the narrative, the investment coming into Northern Ireland is mainly in the services area, and the services are of course outside and have nothing to do with the Windsor Framework. That is where the growth is in Northern Ireland. He said references to the all-Ireland economy were removed as a result of the Windsor Framework, but, of course, every piece of legislation under the Windsor Framework is to align Northern Ireland with the rest of the EU and the Republic of Ireland, rather than the rest of the United Kingdom. That is the fundamental problem with the Windsor Framework—which he well knows, because we have debated this many times.

On this SI, I ask the Minister to address the point that was raised by the Secondary Legislation Scrutiny Committee. The Government said that the 2016 directive, which would be implemented by these regulations,

“already applies in NI as international law by consequence of the Windsor Framework’s ratification”.

The Secondary Legislation Scrutiny Committee, in paragraph 81 of its report, was scathing about the Government’s responses, saying that this was completely untrue. I wonder whether the Government will take the opportunity tonight to deal with that assertion by the committee that this is “incorrect”.

What we have been asked to scrutinise is a done deal. We do not have the opportunity in either House of this Parliament, or elsewhere, such as in Stormont, to change what is before us. It has already been decided by others and imposed upon us. It is striking that in their answers to the Secondary Legislation Scrutiny Committee, the Government set out how extensive the discussions had to be with the European Commission to reach a consensus and to engage closely with it on the legal drafting and timelines for implementation.

There was no such consultation, close detailed negotiations or discussions with anyone in Northern Ireland. The noble Lord, Lord Bew, is right to raise once again the issue of public consultation. The Government said in their response to the Secondary Legislation Scrutiny Committee that

“the scope for policy discretion in how the Directive is reflected in domestic law is limited”.

That is an understatement if ever there was one. That is why they did not consult with anyone other than the Department for Infrastructure and Translink.

These are serious matters. Every time we examine these regulations and SIs, we come back to the fundamental themes: laws being imposed upon us; the lack of any proper, convincing consultation with those affected by it; and divergence between Great Britain and Northern Ireland. I would like the Minister to explain whether he sees any risk to the supply chain for industries in this area in Northern Ireland.

I note that in their response to the scrutiny committee, the Government said that they

“have no active plans to implement the content of the 2016 Directive in Great Britain”.

They have spent enormous amounts of time negotiating with the EU about imposing it on a part of the United Kingdom. Can the Minister tell us: if it is good for Northern Ireland why is it not being considered for the rest of the United Kingdom? Having done all this work, it would be simple to transpose it to rest of the United Kingdom as well. What is the reason for not doing that?

Finally, can the Minister set out in detail the consultation arrangements with the Northern Ireland Department for Infrastructure to ensure that there is not a lot of divergence? The Government said that these arrangements were

“effective during the first major revision of Britain’s National Technical Specification Notices for rail interoperability”.

I would like to know: who is engaged in those arrangements; what is the accountability mechanism; and how do Northern Ireland Assembly Members interact with them?

I thank the Minister for introducing these regulations but if the noble Baroness, Lady Hoey, pushes for a vote, we will certainly be in the Lobby with her.

20:41

[Lord Hay of Ballyore (DUP)]

My Lords, I am grateful to the noble Baroness, Lady Hoey, for bringing forward this regret amendment. The regulations before the House concern railway interworking in Northern Ireland and arise from arrangements linked to international and post-Brexit obligations.

Members may differ on the merits of the regulations themselves. I want to focus on an issue that should concern this House as well as elected representatives in Northern Ireland. Decisions affecting Northern Ireland continue to be made with insufficient consultation and very little accountability, in not only this issue but others. Consultation is not a perceived nicety; it is a fundamental part of good government. Decisions which affect the people, business and infrastructure of Northern Ireland should not be presented simply as, “Take it or leave it”. Those who will be affected by such changes should have a meaningful opportunity to express their views before decisions are taken, not merely after they have been announced.

Too often Northern Ireland finds itself in the position of being informed rather than consulted. That approach risks creating a sense of detachment and frustration among those who are expected to live with the consequences. There is also the question of accountability. One of the strengths of our constitutional arrangements is that Ministers can be questioned, challenged and held to account by Parliament. Yet where regulations flow from external obligations or complex arrangements there can be a growing perspective that responsibility becomes very diluted.

Those in Northern Ireland have a right to expect that decisions affecting their transport, infrastructure, economy and daily lives will not simply be handed down to them. Whether one supports or opposes these regulations, surely, we can all agree that people should have a meaningful opportunity to influence decisions before they are made, not after. Whatever view we take on the merits of these regulations, we should insist that Northern Ireland’s voice be heard and that decision-makers remain answerable for the consequences of their decisions.

This House has frequently emphasised the importance of engagement, transparency and public confidence in decision-making. These principles should apply no less to Northern Ireland than to any other part of this United Kingdom. For these reasons, the regret amendment in the name of the noble Baroness, Lady Hoey, performs an important service: it reminds all of us in this House that good government depends not only on what decisions are made but how they are made. I am fairly supportive of the regret amendment.

20:45

[Lord McCrea of Magherafelt and Cookstown (DUP)]

My Lords, it is important that we debate these regulations, because if they come into effect, they will end the existing arrangements that testify to the reality of the United Kingdom of Great Britain and Northern Ireland, subject to a common legal framework in relation to railways. They cut our country in two, placing one part under a single regime and the other part under another. What is striking about this is that the law that is being applied to one part of the country through the regulations is not the legislation of a devolved legislature within the United Kingdom that reflects the wishes of the devolved legislators, who, in turn, reflect the wishes of their constituents. In actual fact, even if the whole Assembly unitedly opposed these, it would make no difference. That is the bottom line. The basic content has been devised by a foreign Parliament, in which the people of Northern Ireland are not represented. To some, that is acceptable, but to those who believe in the United Kingdom, it is not. This is an extraordinary humiliation of not only the people of Northern Ireland but the whole United Kingdom, which is, through this imposition, having its integrity disrespected by 27 states.

We know that the doctrine of recognition in international relations means that diplomatic relations can be obtained between two or more sovereign states if they recognise each other’s territorial integrity on a reciprocal basis. However, through these regulations, the EU 27 not only refuse to recognise the territorial integrity of the United Kingdom by means of claiming a right to make the laws of the United Kingdom but they, in effect, make those laws and, in so doing, undermine the territorial integrity of the UK. This is in stark contradiction and violation of international law, which states that every state shall refrain from any action

“aimed at the partial or total disruption of the national unity and territorial integrity of a State or country”—

that is according to the declaration of the United Nations. These regulations testify to the efforts of 27 states to do the exact opposite: to disrupt the national unity and territorial integrity of the United Kingdom.

To those who say that the regulations will ensure that the railways of the United Kingdom and Northern Ireland connect with those of the republic, implying that this is somehow providing a convincing argument, I remind them that while we in this country are more used to sea borders than land borders, most countries have rail borders with other countries, many of them on more than one front. However, even those that have only one rail border with another country do not find it a reason to subject itself to the laws of the neighbouring country. The United Kingdom and the Republic of Ireland should approach the question of how railway lines move from one country to another—as other sovereign states do—by means of agreement, not by dictating the laws in a foreign Parliament that the people of Northern Ireland have no representation in.

The indignity has been greatly compounded by the decision of our Government not to hold a public consultation on this legislation, which runs through many provisions and is more like a Bill than a statutory instrument, albeit amendable. Of course, one can understand the logic. What is the point of having consultation? The United Kingdom will still have to bow in submission to the legislation set by parliamentarians elected to represent the constituents of other countries, not Northern Ireland. However, this only serves to underline the reality of our humiliation. Not only will the people of Northern Ireland be disfranchised; now they are not even worthy of consultation.

Perhaps the Minister can explain whether the Government are content to allow divergence. When the legislation comes into force, the standards in Great Britain will be different from those in Northern Ireland. The supply to run our railways that previously came from GB will no longer be able to come unless GB suppliers are prepared to go through the problem of getting the EU declaration of conformity under regulations. There is a push to redirect our supply chain from the rest of the United Kingdom to the Irish Republic—and those who support the Windsor Framework would be quite happy with that.

20:50

[Baroness Suttie (LD)]

My Lords, I join the Minister in sending our very sincere condolences to the people of Spain regarding the truly awful railway accident that happened today. Our heart goes out to the families of those who have lost loved ones.

I thank the Minister for his explanation of these regulations and the noble Baroness, Lady Hoey, for the opportunity of this short debate through her amendment. We on these Benches support the regulations. In many of the debates we have had stemming from the Windsor Framework, there have been understandable and justifiable concerns about the framework leading to increased divergence between Northern Ireland and the rest of the United Kingdom where previously, any divergence was minimal. In the case of these regulations, however, Northern Ireland’s and Britain’s railways run to different specifications and gauges, for historical and geographical reasons. Northern Ireland’s rail network inevitably must connect with the rail network in the Republic of Ireland. However, until a tunnel is built under the Irish Sea, there is no direct rail connection between Northern Ireland and Great Britain.

Like the noble Lord, Lord Dodds, I am very grateful to the Secondary Legislation Scrutiny Committee of your Lordships’ House for the short but excellent and extremely useful report on these highly complex and long regulations. As the report states, there has been a considerable delay in implementing the 2016 EU directive in Northern Ireland, which is required under the Windsor Framework. The Minister referred to this in his introduction, but I am sure he will admit that to most people, this seems an exceptionally long delay before implementation. The committee’s report also stated that there are no active plans to implement the 2016 directive in Great Britain, but that there will be a review as to whether greater alignment with the directive might be beneficial. Can the Minister say when he expects the findings of that review to be published?

As usual in these debates, the concerns are less about the regulations themselves and more about the understandable constitutional and parliamentary scrutiny issues stemming from the Windsor Framework and the adoption of EU law when there is no longer any direct UK involvement in the drafting of that law. However, these regulations are implementing a 2016 EU directive that was drafted and agreed upon when we were still a member of the European Union. In previous debates, I have shared the concern of the noble Lords opposite about the lack of parliamentary scrutiny. It is something we all need to be concerned about. As other noble Lords have said, it is also highly regrettable that there was not wider consultation.

As there are now more moves towards greater alignment with the European Union, which we on these Benches welcome, it is equally important that new and improved ways be found to allow this Parliament to have a greater say and involvement, especially at the earliest stages, when legislation is being drafted. This is particularly true, as I have said in previous debates, because the House of Commons no longer has a European Scrutiny Committee. I hope it will rectify this very soon.

20:54

[Lord Moylan (Con)]

My Lords, I thank the noble Baroness, Lady Hoey, for her regret amendment. I join the Minister and the noble Baroness, Lady Suttie, in expressing the condolences of these Benches to the people of Spain and to those affected by today’s tragic accident in Spain.

I start by acknowledging that the EU has a legitimate interest in railways that springs from the need for interoperability between national systems if its single market is to be perfected. It explains, for example, why the EU has been requiring adoption of a single signalling system throughout its realms. But that goal of interoperability is and will remain a complete chimera as far as Ireland is concerned. As the noble Lord has already explained, the Railway Regulation (Gauge) Act 1846 settled on a standard gauge of four foot, eight and a half inches for Great Britain and an Irish gauge of five foot, three inches for the railways of Ireland. For reasons too lengthy to explore now, the standard gauge was adopted in time throughout most of western Europe, while the Irish gauge established itself only in parts of Australia and Brazil—presumably there were Irish engineers there.

It follows that no European train, indeed no British train, could run in Ireland because it would not fit the tracks, even if the considerable difficulties of transporting it across the substantial body of water that separates Ireland from her nearest neighbour in the European Union could be overcome. The argument of interoperability for EU involvement in Ireland’s railways, north and south, therefore fails dismally.

These regulations replace for Northern Ireland alone the Railways (Interoperability) Regulations 2011, which have, until now, governed rail interoperability across the whole United Kingdom. It is worth stating that cross-border arrangements in Ireland—arrangements which include practical co-operation between railway authorities on both sides of the UK-Irish border—have never been criticised for a lack of effectiveness in the operation of Irish trains. I am sure there has very occasionally been cause for complaint, but generally the system works well. In the place of those regulations, Northern Ireland is to implement the 2016 EU directive, together with the technical specifications adopted under it.

Regulation 2 defines both the directive and those specifications as they are

“amended from time to time”.

Therefore, this is dynamic alignment in perpetuity. This means that the rules governing Northern Ireland’s railways will change not just today but in the future, whenever the European Commission chooses to change them, without any further Act of this Parliament and without any vote in the Northern Ireland Assembly. The mechanisms of democratic consent and the Stormont brake, whatever their merits, offer scant means of effective objection.

The Minister wants a single directing mind in charge of Great British Railways. He seems to be happy that it should be a single directing foreign mind based in Valenciennes, of all places, in charge of railways in the rest of the UK. I do not criticise my right honourable friend Rishi Sunak for not having the Railway Regulation (Gauge) Act 1846 at the front of his mind when he negotiated the Windsor Framework. None the less, it is not right that people in one part of the United Kingdom should be governed by rules in whose making they have no say. I would have expected the European Union, with its long-standing commitment to democratic norms, to be the first to understand that.

The regulations have some intriguing implications. They require the whole of Ireland to adopt the European rail traffic management system—the single European Union signalling system that will allow interoperability with trains that cannot get to Ireland and will not fit the tracks if they do. Why is the British taxpayer paying for this in respect of Northern Ireland? Is this what the people of Northern Ireland want? We will never know. There has been no public consultation; manufacturers, suppliers, those who work on the railway and, above all, passengers get no say. Can the Minister explain why? He has been asked this by a number of noble Lords.

We have never taken the view that the Windsor Framework was the final word or beyond improvement in what is an evolving situation. We will always look at constructive proposals for change and reform. One such proposal would have been persuading the European Union not to proceed with these frankly daft regulations. It would be good to hear from the Minister whether His Majesty’s Government ever approached Brussels with such a proposal. We need to ensure that legislation works for all parts of the United Kingdom; this does not. For that reason, if the noble Baroness divides the House, we will support her.

21:00

[Lord Hendy of Richmond Hill (Lab)]

My Lords, I thank noble Lords for their contributions to today’s debate and for the thoughtful points that have been raised. I will briefly respond to the issues that have featured in this debate.

Noble Lords raised the question of consultation. The Government carefully considered whether a formal public consultation was appropriate. These regulations implement obligations that the United Kingdom has already entered into under the Windsor Framework and COTIF. As a consequence, there was limited policy discretion available regarding the fundamental policy outcome. However, that does not mean that engagement did not take place. The department worked closely with those organisations most directly affected by the legislation, including, as I have said, the Department for Infrastructure, Translink, the Office of Rail and Road, the Rail Safety and Standards Board, and conformity assessment bodies. That engagement informed the practical approach to implementation adopted in these regulations.

As I said in my opening speech, the railway supply industry trade body for Great Britain and Northern Ireland, the Railway Industry Association, has reported no adverse effects so far and no anticipated adverse effects for its members. That deals also with the point about the impact on business, because the business of maintaining and improving railways is very limited, and many of the people who do it are members of the Railway Industry Association.

I will write to the noble Lord, Lord Dodds of Duncairn. He asked a number of questions and it would be more convenient if I wrote to him with all the answers.

The noble Baroness, Lady Suttie, raised the question of the delay, which the SLSC raised. As I outlined in my opening remarks, substantial technical and legal work has been undertaken to ensure that the framework could operate effectively alongside existing domestic railway legislation and provide a workable, durable and legally robust regime for industry and regulators. It is a complex set of regulations—it has taken quite a long time to achieve—but it is the right thing to do in these circumstances. The noble Baroness also asked about the review. The outcome of the review will be published by March 2027, in the post-implementation review of the Great Britain implementation regulations.

These regulations provide the legislative framework necessary to implement the UK’s obligations relating to railway interoperability in Northern Ireland and to update domestic legislation implementing the International Convention concerning Carriage by Rail. They provide clarity and certainty for regulators, infrastructure managers, operators and manufacturers, support the continued operation of cross-border railway services on the island of Ireland, and ensure that domestic legislation accurately reflects the UK’s international obligations. They are the right solution for Northern Ireland’s railways and the industry that supplies them, given the unique technical characteristics of rail across the island of Ireland.

As I said, the eight train sets for the Enterprise service from Belfast to Dublin, ordered jointly between the two Governments, demonstrate precisely the benefit of these regulations. The vehicles will run on the railways of both countries, under a set of rules which are absolutely the same in both. That relative simplicity has enabled a cheaper purchase, and from a supplier in the European Union which is familiar with the regulations.

They are technical regulations, but they perform an important function in providing a clear, stable and legally operable framework for the railway industry in Northern Ireland. I therefore commend the draft regulations to the House.

21:04

[Baroness Hoey (Non-Afl)]

My Lords, I thank the Minister for his response, and I hope he will write on the questions that were not answered in the time available, particularly those to do with the supply across the United Kingdom and the costs.

Anyone who has listened to this debate tonight can see, particularly after what the noble Lord, Lord Moylan, said, that this is a nonsense. These are nonsense regulations in the way that they are being done and the fact that we really do not need them in this sense. We certainly do not need the European Union telling us what to do when it has no interest, in that sense, to do with the railways.

I want to correct one thing that the noble Lord, Lord Bew, said. He said that the Windsor Framework had a huge majority in the Commons. I remind him that that vote was no more a vote on the Windsor Framework than the vote on tonight’s regulations. We have never had a vote on the Windsor Framework. It was a vote on the Windsor Framework (Democratic Scrutiny) Regulations, and I think that is very important. I understand about the regulations tonight, and I accept that both Front Benches and probably everyone who has read all 58 pages will recognise that they are probably needed in that sense, but we should not be doing it in this way. As far as the Windsor Framework is concerned, this has to be looked at. It is unsustainable. We cannot keep having other parts of the world that should have no say in our country dividing our country with statutory instrument after statutory instrument. Because of that, and because I think it is important that we recognise what these SIs are doing, I would like to press my amendment on consultation, of which there was none.

21:06

Division 1

Amendment to the Motion disagreed.

Ayes: 20

Noes: 63

21:17

Motion agreed.

Health Bill

Wednesday 28th October 2026 Lords Chamber

Committee (1st Day) (continued)

21:18

Clause 4: Reducing inequalities

Amendment 12

Moved by

[Lord Rennard]

12: Clause 4, page 3, line 29, at end insert—
“(c) reduce inequalities in the prevention, diagnosis and treatment of diabetes, including variation in access to structured education, glucose monitoring technology and insulin pump therapy.”Member's explanatory statement
This amendment would make diabetes-related health inequalities an explicit, named consideration within the Secretary of State’s general duty to reduce inequalities, rather than leaving diabetes provision to be addressed only implicitly.

[Lord Rennard (LD)]

My Lords, my father might be considered to have been lucky in that, despite losing a leg in the First World War and developing diabetes in the 1920s, that was the decade in which insulin was developed, and it saved his life. His treatment with insulin was so successful that it enabled me to be born in 1960, when he was over 70. When I developed diabetes myself in my 30s, it got way out of control, and I needed daily insulin injections for 20 years. But with great support from St. Thomas’ Hospital, making major lifestyle changes, obtaining a continuous glucose monitor, and being prescribed Mounjaro, I was able to come completely off insulin two years ago. My long-term blood sugar levels have now fallen to just 41 millimoles, which is below the pre-diabetic range.

But many people are much less fortunate than me and do not get the care I do. The prevalence of diabetes is increasing. Over 4.6 million people in the UK live with a formal diabetes diagnosis, and that is predicted to exceed 5 million very shortly. An estimated 1.3 million people are living with undiagnosed type 2 diabetes, while 5.7 million adults in England live with pre-diabetes. In total, more than 12 million adults, one in five, are living with diabetes or pre-diabetes. The direct cost of diabetes care to the NHS has been estimated at £10.7 billion per year, representing around 10% of the entire NHS budget. When indirect impacts are included, total costs exceed £23 billion to £26 billion annually. Diabetes UK estimates that this will surge to between £39 billion to £44 billion per year by 2035 if current trends continue.

Most damningly, 80% of this vast expenditure is spent not on proactive care but on treating people with largely preventable complications. Every week across the UK, there are many preventable complications arising from diabetes: on average, 812 strokes, 568 heart attacks and 2,909 cases of heart failure. In England alone, there are more than 160 lower-limb amputations every week, four out of five of which could be avoided with timely high-quality care. People with diabetes occupy one in every six hospital beds, and diabetes is taking a severe toll on economic productivity. The more than 360,000 working-age adults living with diabetes are now economically inactive due to long-term sickness, a 43% increase in seven years. We cannot continue to address this crisis with short-term financial thinking. Treasury models such as those we are hearing much about today too often demand short-term savings within tight budgetary cycles, ignoring the immense long-term savings that could result from preventing complications.

Nowhere is this short-termism more evident than in the unwarranted regional variations and postcode lotteries exposing vulnerable patients across our health system. The flagship Getting It Right First Time national report on children and young adults, published this year, reveals alarming disparities across England’s integrated care boards. For the 56,000 children and young adults living with type 1 diabetes and the 9,000 with early onset type 2 diabetes, median blood sugar control ranges from just below 55 in top performing units to over 70 in others. While some paediatric units complete all essential annual care checks for 98% of young patients, others achieve just 6%. Patients are literally forced to move house across ICB boundaries just to access life-changing technology.

We now possess transformative tools that can eliminate these disparities if made consistently available. Continuous glucose monitors, or CGMs, have reached over 60% of people with type 1 diabetes, yet access remains quite restricted for those with type 2 diabetes who, like me, could benefit from them immensely. Similarly, while over half of children with type 1 diabetes now use hybrid closed loop systems, known as artificial pancreas systems, overall adult pump provision in the UK stands at just 15%, compared to over 60% in the United States and far higher rates across Europe. Furthermore, for those under 18, hybrid closed loop uptake ranges from 37% to 79% across different ICBs.

Equally vital is the issue of early diagnosis, intervention and specialised care. Currently, 25% of individuals with type 1 diabetes and up to 30% of children and those from deprived backgrounds are diagnosed with diabetes only when presenting in emergency departments with life-threatening diabetic ketoacidosis, known as DKA. Evidence from Germany demonstrates that systematic early screening reduces DKA presentation rates from 30% down to just 2.5%.

Likewise, we must confront the alarming rise of early-onset type 2 diabetes among working-age adults and under-40s. As we approach yet another major NHS reorganisation, we need to guarantee long-term sustainable funding for targeted initiatives such as the NHS T2Day programme and the type 2 diabetes path to remission programme, while rolling out at greater pace GLP1 medication supplies, such as Ozempic and Mounjaro, for many more people with diabetes.

This brings me directly to the amendments tabled in my name after Clause 84. If we plan to abolish NHS England, we must address a critical moment of vulnerability for our public health infrastructure. My first amendment would establish a statutory requirement for the Secretary of State to secure the continuity of key national diabetes programmes to at least the same extent as before the potential abolition of NHS England. This encompasses the NHS diabetes prevention programme, the type 2 diabetes path to remission programme, national provision of continuous glucose monitors, the rollout of hybrid closed-loop technology, and essential diabetes audits, including those for foot care and in-patient safety. It would require an explanatory statement on continuity before making any transfer schemes, alongside annual mandatory reports laid before Parliament, detailing patient access, waiting times and clinical outcomes.

My second amendment would require the Government to publish annual assessment reports over the next four years, specifically evaluating the impact of NHS England’s abolition on diabetes services. These reports must scrutinise changes in funding allocations, the operation of clinical audits, patient access to glucose monitoring and insulin delivery services, as well as specialist workforce capacity.

Consistency in high-quality care, equitable access to modern technology, robust prevention and early diagnosis are not luxury add-ons; they are the essential building blocks of a sustainable healthcare system, a productive economy and a healthy society. I therefore hope that the Minister will see how these amendments would protect national diabetes services, enforce parliamentary accountability and ensure that we give millions of people living with diabetes the care they need, which is very much in the national interest. I beg to move.

[Lord Hunt of Kings Heath (Lab)]

My Lords, it seems that this goes to the heart of some of the issues we were discussing in relation to the noble Earl’s Amendment 4. It is about the balance between what the noble Lord, Lord Rennard, is attempting to seek, which is much more central direction in relation to diabetes services, and the wish for the NHS to be able to make its own decisions locally. Going back to the round table that we had on Monday, the CEO of the NHS Alliance was concerned about central interference, as I think he would call it, into decisions made locally.

21:30

Take diabetes, on the other hand, and the kind of variations that the noble Lord has spoken about. When you consider the scale of the issue, the impact it has on population health and the cost it has to the health service, it is almost unbelievable that you can have such variations. There is a pushback here to people in the service, because how can it be justified that, in such an important disease area, these kind of variations are allowed? Why is diabetes not one of the top five priorities for integrated care boards? It does not appear to be. It is sometimes difficult to work out how ICBs make their decisions in relation to prioritisation.

It is a salutary reminder that one of the reasons why we wish to have central interventions is that the local NHS seems incapable of sorting out things such as this. I am not sure about the noble Lord’s amendments, but I think his aims are very important.

[Baroness Pidgeon (LD)]

My Lords, these amendments tabled by my noble friend Lord Rennard raise some important points and are intended to safeguard national diabetes services following the planned abolition of NHS England, and to ensure that patients do not lose access to proven programmes during that transition.

This is a point that has come to me time and again from different charities representing different disease groups. They are concerned that the specialism and some of the services that are commissioned will be lost. I am sure we will discuss this again on other Committee days.

As we have heard, diabetes is one of the greatest health challenges facing us all. According to Diabetes UK, over 12 million people in the UK are living with diabetes or prediabetes, and it costs the NHS around £10.7 billion every year. That expenditure is linked to complications that can often be prevented through early intervention, effective treatment and consistent monitoring, as well as routine diabetes care.

The amendments would therefore require the Secretary of State to maintain, at a minimum, the current provision of key national programmes. As we have heard, these include the NHS type 2 diabetes prevention programme, the diabetes path to remission programme, continuous glucose monitoring, the rollout of hybrid closed-loop technology and the national diabetes audit programme. I flag that the type 2 diabetes prevention programme is recognised as a world-leading prevention intervention. We do not want to see that lost with this reorganisation.

The amendments would also strengthen transparency and accountability. Before any transfer of functions, the Secretary of State would be required to set out how continuity of these services would be guaranteed. Annual reports to Parliament would then provide clear information on patient access, waiting times and outcomes, while separate assessments over the first four years following the abolition would monitor the impact on funding, workforce capacity or clinical audits, and access to technologies.

At a time when diabetes continues to rise and the impact felt both by individuals and financially throughout the NHS is so significant, it is essential we have confidence that these vital national programmes will not only survive the organisational change but continue to improve outcomes for people living with diabetes. I look forward to hearing the Minister’s response.

[Earl Howe (Con)]

My Lords, I too am grateful to the noble Lord, Lord Rennard, for bringing forward these amendments and for drawing the Committee’s attention to the important issue of diabetes prevention, treatment and care. I particularly welcome the focus in these amendments on innovation, because this is an area in which we see some genuinely promising developments. One example, mentioned by the noble Lord, Lord Rennard, and the noble Baroness, Lady Pidgeon, is the emergence of hybrid closed-loop systems. For people living with type 1 diabetes, this technology has the potential to make an enormous difference.

In April 2024, NHS England began a five-year programme to roll out this technology to eligible children, young people and adults living with type 1 diabetes. That was a very welcome development, and I hope we will continue to see the programme expanded so that more patients who would benefit from the technology are able to access it. It would be helpful to hear from the Minister about that, and about how the rollout of the programme is progressing and how many patients have received the technology so far. As with any issue like this, improvements in accessing the technology are always forefront of commissioners’ minds, so it would be helpful if the Minister can say anything about that. I would also be interested to hear what assessment the Government have made of the availability of specialist staff to support this rollout. Developing an effective new technology is one thing; ensuring that patients can access it, and that clinical teams have the resources and expertise to provide it, is another.

More widely, these amendments raise an important question about the future scale and impact of diabetes in this country. The noble Lord, Lord Rennard, highlighted the statistics and predictions from the International Diabetes Federation. Those predictions present a considerable challenge for not only patients and their families but for the health service. They also reinforce the importance of prevention, particularly in relation to type 2 diabetes, where earlier intervention can make a considerable difference. Can the Minister tell us what steps the Government are taking to strengthen prevention and early diagnosis and to support the wider adoption of new technologies?

Finally, I want briefly to touch on Amendments 225 and 226, which raise a wider point about the abolition of NHS England and the continuity of existing national diabetes programmes. During our consideration of the Bill, we have discussed at some length the importance of ensuring that the abolition of NHS England does not disrupt the delivery of essential services or lead to the loss of programmes and expertise that are already delivering benefits to patients. The noble Lord is absolutely right to raise that concern in the context of diabetes. I am not necessarily persuaded that we need to place each of these requirements in statute, but he raises some entirely legitimate questions. I would welcome assurances from the Minister that these programmes will continue to receive the attention and support they require throughout the transition. I look forward to what the Minister has to say.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, I am most grateful to the noble Lord, Lord Rennard, for tabling this amendment, and to other noble Lords for their contributions. The Government recognise the importance of high-quality diabetes prevention, treatment and care services, and I believe that our actions on this reflect that. Programmes such as the NHS Diabetes Prevention Programme, the NHS Type 2 Diabetes Path to Remission Programme and the National Diabetes Audit all play an important role in improving outcomes for people living with diabetes.

I turn specifically to Amendments 225 and 226. The Bill allows for the transfer of functions and responsibilities from NHS England following its abolition—that means a transfer that will not impact service provision. I say to the noble Earl, Lord Howe, that the Government support effective diabetes services and innovations in various ways, but that includes ensuring the continued commissioning, monitoring and improvement of these programmes without the need for disease-specific provisions in primary legislation. Moreover, specifying programmes at this level of detail would restrict our ability to adapt to new and changing evidence on effective treatments and technologies; I know that is something noble Lords would not want to restrict. Similarly, a diabetes-specific reporting clause would duplicate existing monitoring and oversight arrangements that provide additional assurance without adding administrative burden and additional bureaucracy.

To turn to Amendment 12, improvement of outcomes for people with diabetes absolutely includes reducing health inequalities, which we debated in an earlier group. That is already captured in the general duty to reduce health inequalities set out in Clause 4. Furthermore, the modern service framework for cardiovascular disease, which was published in July, advocates a holistic cardiovascular/kidney/metabolic approach, including finding those with undiagnosed or unmanaged diabetes, initiating treatment and increasing the number of people whose treatment is optimised, with a strong focus on reducing inequalities.

On Amendment 25, I reassure your Lordships that the Secretary of State and the NHS already have powers to promote innovation across the health service. The risk of singling out diabetes technologies in primary legislation is that it would create inconsistency with the approach taken for other conditions. Rollout of glucose monitoring and automated insulin delivery technologies is already supported through NHS implementation arrangements, based on established NICE guidance. Therefore, listing specific technologies in legislation could reduce the flexibility of the NHS to be as truly innovative as we would all want, as new technology emerges.

[Lord Rennard (LD)]

My Lords, I thank the Minister for her sympathy on these issues, and I thank all the people in her department, who I know are sincerely committed to trying to help people with diabetes, to help prevent its occurrence and to provide the best possible care and treatment. But at the heart of the problem, as the noble Lord, Lord Hunt of Kings Heath, said, is a dilemma: as people try to treat medical conditions such as diabetes differently and say there should be a localist approach, there is a fundamental problem for the whole of the country in that, if we fail to deal with this, the cost is on all of us. The costs to taxpayers, the costs of people not working, the costs of not paying to HMRC and the costs of drawing down on the DWP are growing enormously. This is such a huge problem that, as we have said at many points today, we have to look across all government sections at how we work together on all these issues. On that note, I beg leave to withdraw my amendment.

Amendment 12 withdrawn.

Amendments 13 to 17 not moved.

Clause 4 agreed.

Amendments 18 to 20 not moved.

Clause 5: Patient involvement and choice

Amendment 21

Moved by

[Lord Hunt of Kings Heath]

21: Clause 5, page 3, line 34, after “carers” insert “, health and care partners,”
Member’s explanatory statement
This amendment seeks to ensure that health and care partners can be involved in decisions about a patient.

[Lord Hunt of Kings Heath (Lab)]

My Lords, clearly, it is not ideal to start a really important debate at this time of night, but I hope noble Lords will feel they are able to take part in it as they would have done if we were doing this at a reasonable time. I have four amendments in this group: Amendments 21, 173, 174 and 214. I am grateful for the support of the right reverend Prelate the Bishop of Newcastle, the noble Baronesses, Lady Finlay and Lady Barker, and the noble Lord, Lord Blackwater.

At Second Reading, many Peers expressed the wish to promote actions that would directly improve the health outcomes and experiences of NHS patients. I believe there is a good opportunity here. There were fewer mentions of social care, yet the lived experience of people reliant on care services, particularly those in residential care, is just as important as that of those treated in hospitals. Many of these considerations also apply to mental health service in-patients. We know that, clearly, many people are fearful of entering hospital. Some say they would rather die than move into a care home. Treatment in mental health units must routinely be enforced by the process of being sectioned, a term that evokes fear.

My amendments are designed to offer all service users the assurance that, if there is someone who matters to them and is prepared to support them when they are receiving care or treatment, not only in their own home, they can nominate that person as their health and care partner. In most cases, this would be an entirely voluntary role, accepted by a spouse or partner, a close relative or a special friend. Some people who live with a paid companion, or individuals with complex needs who employ a personal assistant, may choose to nominate that person as their health and care partner. The essential element is that it must be the individual who makes the choice.

21:45

When I first raised this matter in your Lordships’ House in December 2022, it was in the wake of the terrible distress caused by the separation inflicted on care home residents and those who loved them during the Covid pandemic. Time did not allow for my Protection of Care Recipients and Carers Bill to proceed, and a similar fate befell a measure entitled the Care Supporters Bill, introduced in the other place in October 2023, which would have included hospital patients as well as care home residents. Instead, the then Care Minister used a statutory power to amend Regulation 9 of the CQC fundamental standards to protect visiting. A review of this legislation published in March this year judged it to have been well intentioned but ineffective. The review promised primary legislation when parliamentary time allows. My view is that the time is now.

The noble and learned Baroness, Lady Hallett, recently published her sixth report from the UK Covid inquiry. She used the language of rights when listing the principles that must determine future policy towards care home residents and those dear to them. For those who were separated from people they loved and had promised to care for, the publication of the report has reopened those wounds.

“This is an open-ended trauma, a wound that won’t close”,

as Jane Wier-Wierzbowska, told the inquiry.

We need to offer a response and offer some solace, and assure people that they have been heard and that action will be taken to ensure that any one of us residing in a care home or entering hospital will always have access to a nominated health and care partner. This person will not be a visitor in their lives; he or she will be an essential component. Enacted within this Health Bill, this would immediately make a tangible difference to patient experience, the quality of care and outcomes. Just consider the difference that it would make to someone whose language is not English, or to someone of any age who suffers from anxiety or cognitive impairment, who may have difficulty understanding what is happening yet may have a very complex decision to make. When someone is approaching the end of life, they need their dear ones more than ever. People who have kept vigil with a dying relative are likely to discover that they can alleviate suffering in small practical ways, in partnership with the clinical team.

The term “health and care partner” may be unfamiliar, but it has been chosen after thoughtful discussion within the NHS, where senior nurses have been meeting with a range of stakeholders to develop a policy that is now ready for implementation. Where it has already been piloted, staff have found it supportive. Patient outcomes have improved and complaints reduced. I have seen a lot of case studies where visitors, relatives and friends, have raised concerns about the person who is resident then found themselves banned from visiting. This is really a very difficult situation. We have to shift the power imbalance in health and care settings. These amendments are one way in which I propose to do so, and I hope that the Government will be sympathetic. I beg to move.

[Baroness Finlay of Llandaff (CB)]

My Lords, I added my name to several of these amendments because I think they are crucial. I read them very carefully to make sure that, in the event of there being major safeguarding concerns, it would not cut across them, and I do not believe it would. I think it will improve care.

It requires a change of attitude on behalf of healthcare staff to accept the fact that sometimes the person who is the relative, the carer who has been looking after someone at home, knows only too well exactly how to communicate with them if they have communication difficulties and how to manage even complex equipment such as their ventilator, sucking them out or whatever. In the hospice where I was medical director, I clearly remember one lady with a horrible tumour; her children wanted to do her dressings for her, and she wanted the children to do them. It was important for those children to be able to help, and encouraged to care as they wanted to, so that they were with her right through her illness. We provided accommodation for them to sleep there when she was dying. We also provided a family room and even had beds that we could put together, so a relative could sleep next to somebody. It really transformed care. It took a lot of pressure off the nursing staff, because there was somebody there all the time and if they became agitated, they could ask for help.

The staff in many units, however, can feel threatened by relatives who say the person would prefer something done one way or another. It is important that if there is someone with a person who is the patient, they have access to food and drink and comfortable seating, not a hard plastic chair, and that it is clear where they can use the toilet or even take a shower and be accommodated. It does not cost anything, but it saves a lot of staff time.

I hope that these amendments will be adopted into the main Bill to bring about that change. Those of us who went to the meeting about DEBRA, which is epidermolysis bullosa, were very touched by the cases we heard in which the mother was doing the child’s dressing changes. It was essential that the mother could go with that child into hospital, and that even when they became an adult they could go on an adult ward, because they knew exactly the least painful way to do the dressing changes. The staff who did not know the person beforehand just did not have the same knowledge and therefore could not apply the same skills.

The noble Baroness, Lady Campbell of Surbiton, spoke very powerfully about the need for a personal health budget. I know she has extensive experience of having her husband with her on many occasions when she has been in hospital, and there have been occasions when he has saved her life. This is not minor. This is very important.

[Baroness Tyler of Enfield (LD)]

My Lords, I underline first of all what the noble Lord, Lord Hunt, said about how very less than ideal it is to be dealing with an important group of amendments of such sensitivity this late in the day, but we are where we are. I very much support the amendments put forward by the noble Lord. I remember clearly my personal anguish at not being able to visit my mother for a long time in her care home. It really was agony for me. What happened during Covid must never be allowed to happen again. I think of those care home residents who died without the love and support of any of their relatives by them. It is an absolute scandal. It is shocking. We must make sure it does not happen again.

My amendments are about unpaid carers and their relationship with the NHS. As we know, unpaid carers have very frequent contact with the NHS, but recognition and support for them can be very variable indeed. This Health Bill presents an important opportunity to place essential rights and support for unpaid carers in legislation for the first time, to bring them on a par with existing rights that carers already have in relation to local authorities. My amendments are designed to improve the identification, health and well-being of carers, as well as improving the provision of breaks, to which they should be entitled.

There are some 4.7 million unpaid carers in England, and the value of carer support is worth £152 billion in England alone. That happens to be about the same as the budget of the whole NHS. We have so many unpaid carers that they are holding the NHS together.

Turning to Amendment 88, on the duty to identify and record unpaid carers, the Care Act 2014 already places duties on local authorities relating to the identification of unpaid carers, but no equivalent duty exists for integrated care boards, which commission in the vast majority to health services. Unpaid carers are more likely to come into contact with health services earlier than they are with local authorities, and there is evidence of significant underidentification of unpaid carers within the NHS. Analysis by the Nuffield Trust of 13 million GP records found that for every one carer identified by GP practices, four were not, meaning around 1 million carers were effectively missing from GP records. So, there are real problems with identification rates, which are compounded by the fact that more carers are identified in affluent areas than in deprived areas.

There are many cogent reasons why identification is important. For example, public health measures can be targeted at unpaid carers, such as free flu vaccinations and assessments for common health problems. Winter pressures on the NHS can be alleviated with targeted support and advice for unpaid carers, and of course, inclusion of unpaid carers in hospital discharge planning could help to reduce avoidable readmissions. That is just to name but three.

The last key point I will make here is that, ironically, unpaid carers can take a long time to identify themselves and understand that they are carers. In fact, some research I saw said that for some 36%, it took up to three years to understand they were a carer. Without a statutory duty, I fear that identification of carers will continue to depend on local priorities and resources. While some areas have excellent systems, others identify very few carers. A statutory duty here would introduce much greater consistency.

Amendment 89 would place a duty on ICBs to promote the health and well-being of carers. I think we all know that unpaid carers consistently experience poorer physical and mental health outcomes than non-carers: they just forget and neglect their own health needs. I have just one statistic here: the GP Patient Survey 2025 found that 72% of carers reported a long-term condition or disability, compared with 60% of non-carers. Many carers are just not able to prioritise their own health. Most tellingly, Carers Week research from last year found that 40% of current carers said they had postponed or cancelled a medical appointment, test, scan, treatment or therapy because of caring. That is an estimated 4.8 million people. My final point here is that ICBs rely heavily on unpaid carers to keep people well at home and reduce hospital admissions. Therefore, supporting carers’ health, I maintain, is vital to NHS sustainability.

Finally, my Amendments 175 and 176 are about a right to a break for unpaid carers and a national respite scheme, and I very much thank other noble Lords who have added their names to these amendments, and to all my amendments in this group. These two amendments essentially do the same thing: they ensure that carers who are assessed as being entitled to a break actually receive one, because although many carers in England are entitled to this assessment under the Care Act, many assessments just do not result in meaningful breaks or replacement care. There are many statistics here, but I will mention just one: official data from 2023-24 shows that only 8% of all unpaid carers were assessed or supported by their local authority, which is a shockingly low figure. Unsurprisingly, carers describe severe exhaustion, burnout, isolation and worsening mental health resulting from being unable to step away from these caring responsibilities.

Local flexibility in the delivery of breaks has too often resulted in inconsistency and postcode variation. Whether an unpaid carer can access a meaningful break should not depend on where they live or the financial pressures facing their local authority. That is why Amendment 176 also establishes a requirement for the Secretary of State to provide financial assistance to deliver this. There was much more I wanted to say, but the time is very late.

22:00

[Baroness Pitkeathley (Lab)]

Noble Lords will not be surprised to know that I give my enthusiastic support to the amendments on unpaid carers in the name of the noble Baroness, Lady Tyler. As she clearly said, one of the great difficulties about the carers’ movement is that people do not identify themselves as carers. That is partly because you become a carer in different ways: sometimes it creeps up on you, and you start by doing your dad’s shopping and then gradually do more for him until you are in a caring situation; or your mum has a stroke and there you are, suddenly in the carer role. Either way, you do not prepare for it, you do not discuss it with anybody, and you certainly do not identify yourself as a carer. That is why having somebody else identify you is of huge importance, and the only way that you are going to identify yourself as a carer and therefore have access to any kind of services at all.

Ironically, although carers have rights with local authorities under various other Acts in the past, they have no rights as far as health services are concerned, and yet it will probably be with their GP that they make initial contact. We did at one point have a duty on GPs to identify carers, but, sadly, that fell by the wayside during a different Government.

Identifying carers should be a duty, to help them and to support that huge workforce. Similarly, that applies to promoting the health and well-being of carers, because, as we have heard, 72% of carers report a long-term condition compared with 60% of people who are not carers. They do not take care of and neglect their own health because they are too busy caring.

As ever with unpaid carers, there is an economic as well as a moral case for supporting them. Here we have this huge workforce of 5 million people providing care worth, as the noble Baroness reminded us, the equivalent of another health service. It is in everybody’s interest to keep them well and doing what they want to do—they do so lovingly and willingly, usually—and to support them as much as possible.

[Baroness Watkins of Tavistock (CB)]

I support the amendments in the name of the noble Baroness, Lady Tyler. I have little to add to what the noble Baronesses, Lady Tyler and Lady Pitkeathley, have said, except to say that, for young carers, regular respite is essential. That might be going to a club once a week, to get out of the house and maintain other connections outside of school, for example. We know how important that is in preventing mental health problems.

There is huge inequality. For three years, I was a carer for my mother, who had Alzheimer’s disease. When I had had enough, I could afford to pay, along with her, to put her into a really nice nursing home for two weeks—which is in fact where she ended up for the last eight months of her life. It is not difficult if you have the money to plan it, but there are lots of people who do not. I cannot emphasise that enough. It kept me well and, in her moments of lucidity, made my mother feel independent, since she was paying to give me a break. We need to think about how difficult it is for people who cannot do that.

Particularly for people with dementia, admiral nurses should be able to identify those carers who are in need of respite. For many people, two weeks may not be what they need; what they need is 24 hours, once a week. Again, the care home that my mother was in is now offering that, and managing to have three people twice a week. That enables other people to go off. I am pleased to say that some of the beds in that nursing home are now paid for by the local authority, so things may be a bit more equitable than they were then.

There is clear evidence that, if you give respite to foster carers, foster carers can go on. Let us learn from that and see how we can apply that to carers right across the country, but with a particular emphasis on those who cannot fund anything to help themselves.

[Lord Young of Cookham (Con)]

My Lords, I will briefly follow in the slipstream of the noble Baronesses, Lady Tyler, Lady Pitkeathley and Lady Watkins, and speak about carers. They all spoke very movingly. I will speak in particular about young carers.

Last week, at Oral Questions, I pointed out that there were 15,000 schoolchildren spending more than 50 hours a week looking after their parents or siblings, and 3,000 of those were aged between five and nine. In that context, I pointed out the disadvantages they face in the field of education: being suspended, arriving late and underachieving. Young carers also underperform —if that is the right word—in terms of mental and physical health. They are rarely identified by the relevant authorities until, on average, three years have passed. In health terms that could include the GP, other health practitioners or those providing mental health services. It takes an average of three years to identify the young carers. Carers Trust polling found that just under a third of young carers said that they felt stressed or worried simply because of their caring role. The GP Patient Survey shows that young adult carers are notably more likely to live with long-term physical health conditions themselves—around 40% for young carers as opposed to 29% for young adults who are not carers.

Despite these health inequalities, very few young carers are identified by health professionals. That was brought home by the recent tragic case in the child safeguarding practice review Cooper and Harris. Two boys were living with their mother who had multiple health issues and had regular emergency hospital admissions. She told the hospital and medical staff several times that her young sons looked after her at home. The ambulance staff recognised the distress experienced by the boys when their mother had a particularly bad fall. Despite this, neither boy was identified as a young carer. Tragically, because the support for that family was not adequate, one of them found his mother lifeless one morning and had to call the emergency services. While the previous NHS long-term plan included specific measures relating to young carers, such as top tips for GPs on improving access to local support for young carers, the current long-term plan does not mention young carers at all.

Amendment 88, as has been explained by the noble Baroness, Lady Tyler, would go a long way to helping improve the identification of unpaid carers of all ages, including young carers, by placing requirements on ICBs to identify them, mirroring the responsibility of local authorities. Amendment 89 would introduce a duty for integrated care boards to promote the health and well-being of carers, including young carers. Through my role as the vice-chair of the APPG for Young Carers and Young Adult Carers, I routinely hear about the impact of caring on the health and well-being of young carers.

The Sutton Trust’s study found that young carers are more likely than young people without caring responsibilities to report severe psychological distress and are more vulnerable to self-harm and attempts on their own lives. The harrowing child safeguarding practice review Molly showed that even though the young carer was identified, professionals supporting Molly’s mother, such as GPs, did not sufficiently consider the needs of Molly, who took her own life with her mother’s medication when she was just 14.

I turn finally to respite care, mentioned by the noble Baroness, Lady Watkins. The provision of regular respite breaks can help support the health and well-being of unpaid carers. One of the things that carers always say makes the biggest difference are breaks. For young carers, respite can take many different forms: young carer groups; trips in the school holidays, which so many miss out on; or even being supported to access opportunities as a family. The Welsh Government actually do this.

These amendments complement the recent Unpaid Carers Action Plan: Recognise, Refer, Reach, which I welcome. I very much hope that the Government can respond sympathetically to this group of amendments.

[Baroness Grey-Thompson (CB)]

My Lords, Amendment 214 complements other amendments in my name. It concerns people with high support needs when they go into hospital and the care that they receive.

At two of my stays in hospital in the summer, I was repeatedly asked whether I had a carer. It felt very patronising as opposed to supportive. However, Second Reading of this Bill gave me another opportunity to have a lived experience of the NHS. This time I spent a week in St Thomas’ Hospital, which was an entirely different experience. It also gave me the opportunity to talk to people who would be affected by this amendment.

Nurses might be trained but not able to offer the appropriate support that someone with high care needs requires. If a person is unwell, it might be difficult for them to explain quite complicated care. There is a real fear among disabled people with high support needs about going into hospital in terms of the impact on their personal health budget—that it might be taken away or changed and about who pays for that care while the individual is in hospital. At a time of great worry, you do not want people to avoid going into hospital because they are worried about their personal health budget.

Hospitals might be accessible but not have the appropriate facilities for disabled people. This is where carers can make a real difference. Another individual contacted me to say that the nursing staff did not know how to use the hoist. It took four members of staff to operate it. It takes one person at home, but that one person was not allowed on the ward to help the individual. In another case, someone with cerebral palsy who was awaiting surgery could transfer to a hospital bed but was told that if they cannot transfer to the surgical bed—which they cannot do—they cannot have the surgery. Their carer is not allowed in to help them, so they are wasting all the pre-operative time. They know that they will be told that they cannot have the surgery.

We need to explore some of these issues further and might be able to in further groups. The current system is, at best, disjointed. We should be able to do better around the whole issue of carers.

[Baroness in Waiting/Government Whip (Baroness Hyde of Bemerton) (Lab)]

My Lords, this would seem to be a convenient time to pause proceedings for the day.

Debate on Amendment 21 adjourned.

House resumed.

House adjourned at 10.13 pm.